united nations a, d, g, i, m1, m2, m3, m4, m5, m6, m7, m8

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United Nations Group 374610- A, D, G, I, M1, M2, M3, M4, M5, M6, M7, M8 PPO Services provided by Empire HealthChoice Assurance, Inc., a licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. The Blue Cross and or Blue Shield names and symbols, including BlueCard, are registered marks of the Blue Cross and Blue Shield Association. AT&T Direct is a registered mark of AT&T. 1/2021 Effective Date 7/1/2020

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United Nations

Group 374610- A D G I M1 M2 M3 M4 M5 M6 M7 M8

PPO

Services provided by Empire HealthChoice Assurance Inc a licensee of the Blue Cross and Blue Shield Association an association of independent Blue Cross and Blue Shield Plans

The Blue Cross and or Blue Shield names and symbols including BlueCard are registered marks of the Blue Cross and Blue Shield Association ATampT Direct is a registered mark of ATampT

12021 Effective Date 712020

wwwempirebluecom 1

Welcome Welcome to Empirersquos PPO With Empire BlueCross BlueShield you have access to great coverage flexibility and all the advantages of quality care This benefits book explains exactly how you access healthcare services what your health plan covers and how we can help you make the most of your plan Si necesita ayuda en espantildeol para entender este documento puede solicitarla sin costo adicional llamando al nuacutemero de servicio al cliente que aparece al dorso de su tarjeta de identificacioacuten o en el folleto de inscripcioacuten YOUR PPO ndash A SMART WAY TO GET HEALTHCARE

The Preferred Provider Organization offers a network of healthcare providers available to you through Empire If you think about your town it includes doctors hospitals laboratories and other medical facilities that provide healthcare services ndash thatrsquos what we mean by healthcare ldquoprovidersrdquo Some healthcare providers contract with health plans like Empire BlueCross BlueShield to provide services to members as part of the planrsquos ldquonetworkrdquo

With Empirersquos PPO when you need healthcare services you have a choice Depending on the healthcare service you need you are free to get care from providers participating in your PPO network or you can choose to use outside providers You are covered for medically necessary services no matter which you choose

WHATrsquoS THE EMPIRE PPO ADVANTAGE

When you use Empirersquos PPO network to access healthcare you get

x A comprehensive Web site wwwempirebluecom for fast personalized secure information x Among the largest network of doctors and hospitals in New York State x Providers that are continuously reviewed for Empirersquos high standards of quality x The ability to choose in-network or out-of-network care for most covered services x Minimal out-of-pocket costs for preventive care behavioral healthcare and a wide variety of hospital and medical

services when you stay in-network x Easy to use ndash no claim forms to file when you stay in-network x Coverage for you and your family when traveling or living outside of Empirersquos service area

HOW TO USE THIS GUIDE

This Guide gives you an overview of the features and benefits of your plan Use it as a reference to find out whatrsquos covered what your costs are and how to get healthcare services any time you or a covered family member need them

Yoursquoll find the information you need divided into sections Herersquos a quick reference

IF YOU ARE LOOKING FOR hellip YOUrsquoLL FIND IT IN ON PAGE

x HOW THE PLAN WORKS USING YOUR PPO 6

x WHATrsquoS COVERED COVERAGE 17

x PRECERTIFICATION AND HEALTH INFORMATION HEALTH MANAGEMENT 41

x HOW TO FILE A CLAIM THE MEANING OF HEALTHCARE TERMS AND YOUR LEGAL RIGHTS

DETAILS AND DEFINITIONS 50

This Guide describes only the highlights of your medical coverage It does not attempt to cover all the details Additional details are

provided in the plan documents and insurance andor service contracts which legally govern the plan In the event of any discrepancy between this Guide and the plan documents the plan documents will govern

2 wwwempirebluecom

OUR ROLE IN NOTIFYING YOU There may be times when benefits andor procedures may change We or your employer will notify you of any change in writing Announcements will go directly to you at the address that appears on our records or to your group benefits office

CONFORMITY WITH LAW Any term of this Booklet which is in conflict with any applicable federal law will be amended to conform with the minimum requirements of such law

wwwempirebluecom 3

Manage Your Healthcare Online

REGISTER NOW TO DO IT ON THE WEB

Go to wwwempirebluecom where you can securely manage your health plan 24 hours a day 7 days a week Herersquos what you can do

x Check status of claims x Search for doctors and specialists x Update your member profile x Get health information and tools with My

Health powered by WebMD

x Print plan documents x Receive information through your personal ldquoMessage Centerrdquo x Visit the Pharmacy

Plus much more hellip

HERErsquoS WHAT YOUrsquoLL NEED TO DO

All members of your family 18 or older must register separately x Go to wwwempirebluecom x Click on the Member tab and choose

ldquoRegisterrdquo

x Follow the simple registration instructions

GET PERSONALIZED HEALTH INFORMATION ndash INCLUDING YOUR HEALTH IQ

Click on MY HEALTH from your secure homepage after you register to receive the following features x Take the Health IQ test and compare your score to others in your age group x Find out how to improve your score ndash and your health ndash online x Find out how to take action against chronic and serious illnesses

Get health information for you and your family

YOUR PRIVACY IS PROTECTED

Your information is protected by one of the most advanced security methods available

Register today to experience hassle-free service wwwempirebluecom

4 wwwempirebluecom

Your PPO Guide

Introduction GETTING ANSWERS YOUR WAY 5

Using Your PPO KNOW THE BASICS 6 YOUR BENEFITS AT A GLANCE 10 DOCTORrsquoS SERVICES 17 EMERGENCY CARE 20 MATERNITY CARE 22 HOSPITAL SERVICES 23 DURABLE MEDICAL EQUIPMENT AND SUPPLIES 25 HOME HEALTH CARE 27 PHYSICAL OCCUPATIONAL SPEECH OR VISION THERAPY 28 BEHAVIORAL HEALTHCARE 29 EMPIRE PHARMACY PROGRAM 30 EXCLUSIONS AND LIMITATIONS 40

Health Management EMPIRErsquoS MEDICAL MANAGEMENT PROGRAM 42 NEW MEDICAL TECHNOLOGY 46 CASE MANAGEMENT 46 PREVENTIVE SERVICES 47 WELLNESS PROGRAMS 50

Details and Definitions ELIGIBILITY 51 CLAIMS 52 REIMBURSEMENT FOR COVERED SERVICES 56 COMPLAINTS APPEALS AND GRIEVANCES 59 ENDING AND CONTINUING COVERAGE 63 YOUR RIGHTS AND RESPONSIBILITIES 65 DEFINITIONS 66 AUDIOHEALTH LIBRARY TOPICS 70 2016 AMENDMENT 75 2017 AMENDMENT 77 2018 AMENDMENT 82 GET HELP IN YOUR LANGUAGE 88

wwwempirebluecom 5

Introduction Getting Answers Your Way Empire gives you more choices for contacting us with your customer service questions Use the Internet phone or mail to get the information you need when you need it

ON THE INTERNET Do you have customer service inquiries and need an instant response Visit wwwempirebluecom At Empire we understand that getting answers quickly is important to you Most benefit claims or membership questions can be addressed online quickly simply and confidentially Nervous about using your PC for important healthcare questions or transactions Wersquove addressed that too Just ldquosend us an e-mail

BY TELEPHONE

WHAT WHY WHERE MEMBER SERVICES For questions about your benefits claims

or membership To locate a participating behavioral healthcare provider in your area Precertification of mental health and alcoholsubstance abuse care

1-855-519-9537 TDD for hearing impaired 1-800-682-8786 830 am to 500 pm Monday ndash Friday

ATT SERVICIOS PARA IDIOMAS EXTRANJEROS

Si usted no habla ingleacutes 1-800-342-9816 Por favor permanezca en la liacutenea y espere que la grabacioacuten termine Un representante de servicios a los miembros contestaraacute la liacutenea y le conectaraacute con un traductor 900 am a 500 pm de Lunes ndash Viernes

BLUECARDreg PPO PROGRAM Get network benefits while you are away from home Locate a PPO provider outside Empirersquos network service area

1-800-810-BLUE (2583) wwwbcbscom 24 hours a day 7 days a week

MEDICAL MANAGEMENT PROGRAM Precertification of hospital admissions and certain treatments and procedures

1-855-519-9537 830 am to 500 pm Monday ndash Friday

247 NURSELINE AND AUDIOHEALTH LIBRARY

Speak with a specially trained nurse to get health information and instructions on how to listen to the tapes

1-877-TALK-2RN (825-5276) 24 hours a day 7 days a week

EMPIRErsquoS PHARMACY PROGRAM Information about the program Locate a participating retail pharmacy Obtain a complete drug formulary list

1-800-342-9816 TDD for hearing impaired 1-800-682-8786 700 am to 1000 pm Monday ndash- Friday 900 am to 900 pm Saturday 900 am to 530 pm Sunday

FRAUD HOTLINE Help prevent health insurance fraud 1-800-I-C-FRAUD (423-7283) 900 am to 500 pm Monday ndash Friday

IN WRITING Empire BlueCross BlueShield PPO Member Services PO Box 1407 Church Street Station New York NY 10008-1407

6 wwwempirebluecom

Using Your PPO

Know the Basics The key to using your PPO plan is understanding how benefits are paid Start by choosing in-network or out-of-network services any time you need healthcare Your choice determines the level of benefits you will receive

You can view and print up-to-date information about your plan or request that information be mailed to you by visiting wwwempirebluecom

CHOOSING IN-NETWORK OR OUT-OF-NETWORK SERVICES In-network services are healthcare services provided by a doctor hospital or healthcare facility that has been selected by Empire or another Blue Cross andor Blue Shield plan to provide care to our members When you choose in-network care you get these advantages

x CHOICE ndash You can choose any participating provider from the largest network of doctors and hospitals in New York State or the network of Blue Cross and Blue Shield plans through the BlueCardreg PPO Program

x FREEDOM ndash You do not need a referral to see a specialist so you direct your care x LOW COST ndash Benefits are paid after a co-payment OR deductible and coinsurance payment for office visits and

many other services x BROAD COVERAGE ndash Benefits are available for a broad range of healthcare services including visits to specialists

physical therapy and home health care x CONVENIENCE ndash Usually there are no claim forms to file x Out-of-network services are healthcare services provided by a licensed provider outside Empirersquos PPO network or the

BlueCard PPO networks of other Blue Cross andor Blue Shield plans For most services you can choose in-network or out-of-network However some services are only available in-network When you use out-of-network services You pay an annual deductible and coinsurance plus any amount above the maximum allowed amount (the

maximum Empire will pay for a covered service) This amount is currently 275 of Medicarersquos Fee Schedule (except for physical therapy services which is 200 of Medicarersquos Fee Schedule and Certified Social Worker which is 225 of Medicarersquos Fee Schedule) if you use a BlueCard provider you will pay only the lower of billed charges or a negotiated rate and your member liability

You will usually have to pay the provider when you receive care You will need to file a claim to be reimbursed by Empire

wwwempirebluecom 7

The following chart shows your specific plan information as of July 1 2013 See the Details and Definitions section for explanations of terms in the chart

IN-NETWORK OUT-Of-NETWORK

ANNUAL DEDUCTIBLE $0 $250Individual $750Family

CO-PAYMENT (for office visits and certain covered services)

$15 per visit (Non-Specialist)

$20 per visit (Specialist)

NA

CO-PAYMENT (for hospital inpatient admissions)

$0 NA

CO-PAYMENT (for emergency room) $75 per visit (waived if admitted to hospital within 24 hours)

$75 per visit (waived if admitted to hospital within 24 hours)

COINSURANCE NA You pay 20 of allowed amount Plan pays 80 of maximum allowed amount

ANNUAL OUT-OF-POCKET LIMIT

(includes Deductible Coinsurance Copayments and cost sharing for Prescription drug coverage)

NA $1250Individual $3250Family

LIFETIME MAXIMUM Unlimited Unlimited

COST SHARE CREDIT If on the day before the effective date of this benefit booklet a member was covered under a group major medical or extended medical contract issued to your group by us or another carrier any covered expenses applied to the in-network and out-of-network deductible and in-network and out-of-network out-of-pocket limit incurred by the member under the prior group contract during the same benefit period will be applied to the satisfaction of any in-network and out-of-network deductible and in-network and out-of-network out-of-pocket limit required under this benefit booklet during the same benefit period for such member for that year only This applies only to members who are covered on the initial effective date of the new benefit booklet with us

HOW TO ACCESS PRIMARY AND SPECIALTY CARE SERVICES Your health plan covers certain primary and specialty care services To access primary care services simply visit any network physician who is a general or family practitioner internist or pediatrician Your health plan covers care provided by any network specialty care provider you choose Referrals are never needed to visit any network specialty care provider To make an appointment call your physicianrsquos office

x Tell them you are an Empire member x Have your Member ID card handy They may ask you for your group number member ID number or

office visit copay x Tell them the reason for your visit

When you go for your appointment take your Member ID card

WHEN YOU NEED CARE AFTER NORMAL OFFICE HOURS After hours care is provided by your physician who may have a variety of ways of addressing your needs Call your physician for instructions on how to receive medical care after their normal business hours on weekends and holidays This includes information about how to receive non-Emergency Care and non-Urgent Care within the service area for a condition that is not life threatening but that requires prompt medical attention If you have an emergency call 911 or go to the nearest emergency room

8 wwwempirebluecom

WHERE TO FIND NETWORK PROVIDERS Empirersquos PPO network gives you access to providers within the planrsquos operating area of 28 eastern New York State counties See ldquooperating areardquo in the Details and Definitions section for a listing of counties

To locate a provider in Empirersquos operating area visit wwwempirebluecom You can search for providers by name address language spoken specialty and hospital affiliation The search results include a map and directions to the providerrsquos office Or ask your Benefits Administrator to see Empirersquos PPO Directory

You can also request that a directory be mailed to you free of charge by calling Member Services at 1-855-519-9537 Call 1-800-810-BLUE (2583) or visit wwwbcbscom to locate participating BlueCard PPOreg providers

TRANSITIONAL CARE Networks grow and change and sometimes a provider will move or leave the network that serves your Plan If you are an existing member and the provider with whom you are in an ongoing course of treatment leaves the network Empire will notify you at least 30 calendar days prior to the physicianrsquos termination or within 15 days after we become aware of the providerrsquos change in status You may continue to receive medically necessary covered services from a provider for an ongoing course of treatment for up to 90 days after heshe leaves the network if the provider agrees to (1) reimbursement at the rates applicable prior to start of transitional care (2) to adhere to the planrsquos quality assurance requirements (3) to provide the plan with necessary medical information related to this care and (4) to adhere to the plans policies and procedures After 90 days you must select a new provider Continued care is available to pregnant women who are in the second and third trimester through the delivery and postpartum period You must contact our Medical Management department to arrange this continued care Transitional care will not be approved if the provider leaves the network due to imminent harm to patient care a determination of fraud or a final disciplinary action by a state licensing board (or other governmental agency) that impairs the health care professionalrsquos ability to practice New plan members who are in treatment for a disabling and degenerative or life threatening condition or disease are eligible for up to 60 days of continued care following their initial enrollment date Members who are pregnant and in their second or third trimester on the effective date of coverage may continue care through delivery and the postpartum period The provider must agree to (1) reimbursement at the rates applicable prior to start of transitional care (2) to adhere to the planrsquos quality assurance requirements (3) to provide the plan with necessary medical information related to this care and (4) to adhere to the plans policies and procedures in both situations You must contact our Medical Management department to arrange this continued care

INTER-PLAN PROGRAMS Out-of-Area Services

Empire has a variety of relationships with other Blue Cross andor Blue Shield Licensees referred to generally as ldquoInter-Plan Programsrdquo Whenever you obtain healthcare services outside of Empirersquos service area the claims for these services may be processed through one of these Inter-Plan Programs which include the BlueCard Program and may include negotiated National Account arrangements available between Empire and other Blue Cross and Blue Shield Licensees

Typically when accessing care outside Empirersquos service area you will obtain care from healthcare providers that have a contractual agreement (ie are ldquoparticipating providersrdquo) with the local Blue Cross andor Blue Shield Licensee in that other geographic area (ldquoHost Bluerdquo) In some instances you may obtain care from nonparticipating healthcare providers Empirersquos payment practices in both instances are described below

BlueCardreg Program Under the BlueCardreg Program when you access covered healthcare services within the geographic area served by a Host Blue Empire will remain responsible for fulfilling Empirersquos contractual obligations However the Host Blue is responsible for contracting with and generally handling all interactions with its participating healthcare providers

Whenever you access covered healthcare services outside Empirersquos service area and the claim is processed through the BlueCard Program the amount you pay for covered healthcare services is calculated based on the lower of

x The billed covered charges for your covered services or x The negotiated price that the Host Blue makes available to Empire

Often this ldquonegotiated pricerdquo will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider Sometimes it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements incentive payments andor other credits or charges Occasionally it may

wwwempirebluecom 9

be an average price based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price

Estimated pricing and average pricing going forward also take into account adjustments to correct for over- or underestimation of modifications of past pricing for the types of transaction modifications noted above However such adjustments will not affect the price Empire uses for your claim because they will not be applied retroactively to claims already paid

Laws in a small number of states may require the Host Blue to add a surcharge to your calculation If any state laws mandate other liability calculation methods including a surcharge we would then calculate your liability for any covered healthcare services according to applicable law

Under certain circumstances if Empire pays the healthcare provider amounts that are your responsibility such as Deductibles Copayments or Coinsurance Empire may collect such amounts directly from you You agree that Empire has the right to collect such amounts from you

Non-Participating Healthcare Providers Outside Empirersquos Service Area Your Liability Calculation

When covered healthcare services are provided outside of Empirersquos service area by non-participating healthcare providers the amount you pay for such services will generally be based on either the Host Bluersquos nonparticipating healthcare provider local payment or the pricing arrangements required by applicable state law In these situations you may be liable for the difference between the amount that the non-participating healthcare provider bills and the payment Empire will make for the Covered Services as set forth in this paragraph

Exceptions

In certain situations Empire may use other payment bases such as billed covered charges the payment we would make if the healthcare services had been obtained within our Service Area or a special negotiated payment as permitted under Inter-Plan Programs Policies to determine the amount Empire will pay for services rendered by nonparticipating healthcare providers In these situations you may be liable for the difference between the amount that the non-participating healthcare provider bills and the payment Empire will make for the covered services as set forth in this paragraph

BLUECARDreg PPO PROGRAM Care When you are Out of Our Service Area Within the US

If you are traveling outside the Empire service area the BlueCardreg PPO program lets you use other Blue Cross andor Blue Shield plansrsquo PPO networks of physicians hospitals and other health care providers As a PPO member you are automatically enrolled in the BlueCardreg PPO program This allows you to receive in-network benefits across the country outside of our network area from providers participating with other Blue Plansrsquo PPO networks As long as these services are covered services under your Contract or Certificate they will be treated as in-network services If you are traveling and need medical care call 1-800-810-BLUE (2583) for the names and addresses of the PPO providers nearest you You may also visit the Blue Cross and Blue Shield Association Web site to locate providers in other states at wwwbcbscom BlueCardpound Worldwide Program The BlueCard Worldwide program provides hospital and professional coverage through an international network of healthcare providers With this program yoursquore assured of receiving care from licensed healthcare professionals The program also assures that at least one staff member at the hospital will speak English or the program will provide translation assistance Herersquos how to use BlueCard Worldwide

x Call 1-804-673-1177 24 hours a day seven days a week for the names of participating doctors and hospitals Outside the US you may use this number by dialing an ATampT Directreg1 Access Number

x Show your Empire ID card at the hospital If yoursquore admitted you will only have to pay for expenses not covered by your contract such as co-payments coinsurance deductibles and personal items Remember to call Empire within 24 hours or as soon as reasonably possible

x If you receive outpatient hospital care or care from a doctor in the BlueCard Worldwide Program pay the bill at the time of treatment When you return home submit an international claim form and attach the bill This claim form is available from the healthcare provider or by calling the BlueCard Worldwide Program Mail the claim to the address on the form You will receive reimbursement less any coinsurance amount above the maximum allowed amount

10 wwwempirebluecom

Your Benefits at a Glance

Empirersquos plan provides a broad range of benefits to you and your family Following is a brief overview of your coverage Some services require precertification with Empirersquos Medical Management Program See the Health Management section for details

YOU PAY

HOME OFFICEOUTPATIENT CARE IN-NETWORK OUT-OF-NETWORK

HOMEOFFICE VISITS $15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

ONLINE VISITS $15 Primary co-payment per visit

Deductible and 20 coinsurance

SPECIALIST VISITS $20 co-payment per visit Deductible and 20 coinsurance

CHIROPRACTIC CARE x Up to an annual in-network and out of network maximum of $1000

$15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

SECOND OR THIRD SURGICAL OPINION $10 co-payment per visit Deductible and 20 coinsurance

DIABETES EDUCATION AND MANAGEMENT $10 co-payment per visit Deductible and 20 coinsurance

ALLERGY CARE x Office Visit x Testing x Treatment

$15 per visit (Non-Specialist) $20 per visit (Specialist) $0 $0

Deductible and 20 coinsurance

SURGERY $0 Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

Empirersquos Medical Management Program must be contacted to determine medical necessity of all in-network and out-of-network chiropractic care after

the fifth visit We will not pay for any visits which we determine were not medically necessary in accordance with your contract

wwwempirebluecom 11

YOU PAY

HOME OFFICEOUTPATIENT CARE IN-NETWORK OUT-OF-NETWORK

DIAGNOSTIC PROCEDURES

x X-rays and other imaging x Laboratory tests

$0 $0

Deductible and 20 coinsurance

CHEMOTHERAPY $0 Deductible and 20 coinsurance

HIGH COST DIAGNOSTIC TESTS (ie MRIsMRAs Nuclear cardiology servicesPETCAT scans)

$0 Deductible and 30 coinsurance

RADIATION $0 Deductible and 20 coinsurance

PRE-SURGICAL TESTING $0 Deductible and 20 coinsurance

ANESTHESIA $0 Deductible and 20 coinsurance

KIDNEY DIALYSIS $0 Deductible and 20 coinsurance

SECOND OR THIRD MEDICAL OPINION FOR CANCER DIAGNOSIS

$15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

CARDIAC REHABILITATION $15 per visit (Non-Specialist)

$20 per visit (Specialist) Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

12 wwwempirebluecom

YOU PAY

HOME OFFICEOUTPATIENT CARE IN-NETWORK OUT-OF-NETWORK

ANNUAL PHYSICAL EXAM x One per calendar year

$15 per visit (Non-Specialist)

$20 per visit (Specialist) Not covered

DIAGNOSTIC SCREENING TESTS x Cholesterol 1 every 2 years (except for triglyceride testing) x Diabetes (if pregnant or considering pregnancy) x Colorectal cancer

ndash Fecal occult blood test if age 40 or over 1 per year ndash Sigmoidoscopy if age 40 or over 1 every 2 years

x Routine Prostate Specific Antigen (PSA) in asymptomatic males ndash Over age 50- 1 every year ndash Between ages 40-49 if risk factors exist 1 per year ndash If prior history of prostate cancer PSA at any age ndash Diagnostic PSA 1 per year

$0 $0

$0

$0

Deductible and 20 coinsurance

WELL-WOMAN CARE x Office visits x Pap smears x Bone Density testing and treatment

ndash Ages 55 through 65 - 1 baseline ndash Age 65 and older - 1 every 2 years (if baseline before

age 65 does not indicate osteoporosis) ndash under Age 65 - 1 every 2 years (if baseline before age

65 indicates osteoporosis) x Mammogram (based on age and medical history)

ndash Ages 35 through 39 ndash 1 baseline ndash Age 40 and older ndash 1 per year

x Womenrsquos sterilization procedures and counseling x Breastfeeding support supplies and counseling

ndash One breast pump per pregnancy x Screenings andor counseling for Gestational diabetes

Human Papillomavirus (HPV) sexually transmitted infections STIs) Human immune deficiency (HIV) interpersonal and domestic violence

$15 per visit (Non-Specialist) $20 per visit (Specialist)

$0 $0

$0

$0 $0

$0

Deductible and 20 coinsurance

WELL-CHILD CARE (covered services and the number of visits are based on the prevailing clinical standards of the American Academy of Pediatrics) x In-hospital visits

ndash Newborn 2 in-hospital exams at birth following vaginal delivery

ndash Newborn 4 in-hospital exams at birth following c-section delivery

x Office visits ndash From birth up 1st birthday 7 visits ndash Ages 1 through 4 years of age 6 visits ndash Ages 5 through 11 years of age 7 visits ndash Ages 12 up to 17 years of age 6 visits ndash Ages 18 to 19th birthday 2 visits

x Lab tests x Immunizations (office visits are not required)

$0

$0

$0 $0

$0

$0

Deductible and 20 coinsurance Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements See the Preventive Care section for more details

wwwempirebluecom 13

YOU PAY

EMERGENCY CARE IN-NETWORK OUT-OF-NETWORK

EMERGENCY ROOM $75 per visit co-payment (waived if admitted to the same hospital within 24 hours)

PHYSICIANrsquoS OFFICE $15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

EMERGENCY AIR AMBULANCE x Transportation to nearest acute care hospital for

emergency inpatient admissions

$0

Covered in-network when specified criteria is met subject to any applicable cost sharing You may be required to pay the difference between the maximum allowed amount and the total charges of an out-of-network provider

EMERGENCY LAND AMBULANCE x Local professional ground ambulance to

nearest hospital $0 up to the maximum allowed

amount

Covered in-network subject to meeting emergency criteria When services are delivered by an out-of-network land ambulance provider that is not licensed under the NY Public Health Law you may be required to pay up to the difference between the maximum allowed amount and the providerrsquos total charges13

MATERNITY CARE IN-NETWORK OUT-OF-NETWORK

PRENATAL AND POSTNATAL CARE (In doctorrsquos office) $0 Deductible and 20 coinsurance

LAB TESTS SONOGRAMS AND OTHER DIAGNOSTIC PROCEDURES $0 Deductible and 20 coinsurance

ROUTINE NEWBORN NURSERY CARE (In hospital) $0 Deductible and 20 coinsurance

OBSTETRICAL CARE (In hospital) $0 Deductible and 20 coinsurance

OBSTETRICAL CARE (In birthing center) $0 Not covered

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

13 New York State law prohibits land ambulance providers in New York State from balance-billing beyond reasonable and customary amounts (you will be responsible for in-network cost share such as co-payments deductibles and coinsurance)

14 wwwempirebluecom

YOU PAY

HOSPITAL SERVICES IN-NETWORK OUT-OF-NETWORK

SEMI-PRIVATE ROOM AND BOARD $0 Deductible and 20 coinsurance

ANESTHESIA AND OXYGEN $0 Deductible and 20 coinsurance

CHEMOTHERAPY AND RADIATION THERAPY $0 Deductible and 20 coinsurance

DIAGNOSTIC X-RAYS AND LAB TESTS $0 Deductible and 20 coinsurance

DRUGS AND DRESSINGS $0 Deductible and 20 coinsurance

GENERAL SPECIAL AND CRITICAL NURSING CARE $0 Deductible and 20 coinsurance

INTENSIVE CARE $0 Deductible and 20 coinsurance

KIDNEY DIALYSIS $0 Deductible and 20 coinsurance

SERVICES OF LICENSED PHYSICIANS AND SURGEONS $0 Deductible and 20 coinsurance

SURGERY (Inpatient and Outpatient) $0 Deductible and 20 coinsurance

DURABLE MEDICAL EQUIPMENT AND SUPPLIES IN-NETWORK OUT-OF-NETWORK

DURABLE MEDICAL EQUIPMENT (ie hospital-type bed wheelchair sleep apnea monitor)

$0 Not covered

ORTHOTICS $0 Not covered

PROSTHETICS (ie artificial arms legs eyes ears) $0 Not covered

MEDICAL SUPPLIES (ie catheters oxygen syringes) $0

Difference between the maximum allowed amount and the total charge ( coinsurance does not apply)

NUTRITIONAL SUPPLEMENTS (enteral formulas and modified solid food products)

$0 Deductible and 20 coinsurance

HEARING AIDS (one device per ear every 3 years maximum of $1500 combined in and out-of-network) $0 Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

Does not include inpatient or outpatient behavioral healthcare or physical therapyrehabilitation For a second procedure performed during an authorized surgery through the same incision Empire pays for the procedure with the higher maximum allowed amount For a second procedure done through a separate incision Empire will pay the maximum allowed amount for the procedure with the higher allowance and up to 50 of the maximum allowed amount for the other procedure $0 outside of the United States

wwwempirebluecom 15

YOU PAY

SKILLED NURSING AND HOSPICE CARE IN-NETWORK OUT-OF-NETWORK

SKILLED NURSING FACILITY Up to 120 days per calendar year $0 Not covered

HOSPICE Unlimited days per lifetime $0 Not covered

HOME HEALTH CARE IN-NETWORK OUT-OF-NETWORK

HOME HEALTH CARE

Up to 200 visits per calendar year (a visit equals 4 hours of care)

$0

Deductible and 20 coinsurance only

HOME INFUSION THERAPY $0 Not covered

PHYSICAL OCCUPATIONAL SPEECH OR VISION THERAPY IN-NETWORK OUT-OF-NETWORK

PHYSICAL THERAPY AND REHABILITATION

x Up to 60 days of inpatient service per calendar year

x Up to 60 visits combined in home office or outpatient facility per calendar year

$20 per visit (Specialist)

$15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

Deductible and 20 coinsurance

OCCUPATIONAL AND SPEECH THERAPY

x Up to 60 visits per person combined in home office or outpatient facility per calendar year

$15 per visit (Non-Specialist) $20 per visit (Specialist) Deductible and 20 coinsurance

VISION THERAPY

x Up to 60 visits per person combined in home or office per calendar year

$15 per visit (Non-Specialist) $20 per visit (Specialist) Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

Treatment maximums are combined for in-network and out-of-network care $0 outside of the United States

16 wwwempirebluecom

YOU PAY

MENTAL HEALTH CARE IN-NETWORK OUT-OF-NETWORK

OUTPATIENT x Up to 60 visits per calendar year 1

$25 co-payment Deductible and 20 coinsurance

INPATIENT x Up to 90 days per calendar year 1

x Up to 90 visits from mental health care professionals

per calendar year 1

$0

$0

Deductible and 20 coinsurance

Deductible and 20 coinsurance

ALCOHOL OR SUBSTANCE ABUSE TREATMENT IN-NETWORK OUT-OF-NETWORK

OUTPATIENT x Up to 60 visits per calendar year including up to

20 visits for family counseling $0 Deductible and 20 coinsurance

INPATIENT x Up to 7 days detoxification per calendar year 1 x Up to 30 days rehabilitation per calendar year 1

$0 $0

Deductible and 20 coinsurance

Deductible and 20 coinsurance

PHARMACY (RETAIL AND MAIL SERVICE) IN-NETWORK OUT-OF-NETWORK

RETAIL PHARMACY (34 day supply) x Tier 1 x Tier 2

x Tier 3

x 20 co-payment $5 minimum and up to a maximum of $20 per prescription

x 25 co-payment $5 minimum and up to a maximum of $30 per prescription

x 25 co-payment $5 minimum and up to a maximum of $30 per prescription

x

40 Coinsurance

(within the United States)

20 Coinsurance

(outside the United States)

x

MAIL SERVICE (90 day supply-includes some specific Retail locations)

x $15 co-payment Not covered

Generic and Select Oral Contraceptives and Contraceptive Devices

x $0 cost share Not covered

(All of the prescription drug options listed above meet the Centers for Medicare and Medicaid Services (CMS) standards for Medicare prescription drug coverage and each option is considered Creditable Coverage under the Medicare Modernization Act of 2003)

OTHER SERVICES IN-NETWORK OUT-OF-NETWORK SEX CHANGE SURGERY OR TREATMENT OF GENDER IDENTITY DISORDERS (for hospital inpatient only) x Lifetime Maximum $75000 for transformative surgeries

Lifetime Maximum combined In-network and Out-of-Network

$0 Deductible and 20 coinsurance

Treatment maximums are combined for in-network and out-of-network care

wwwempirebluecom 17

Coverage

Doctorrsquos Services When you need to visit your doctor or a specialist Empire makes it easy In-network you pay only a co-payment There are no claim forms to fill out for X-rays blood tests or other diagnostic procedures ndash as long as they are requested by the doctor and done in the doctorrsquos office or a network facility For in-network allergy office visits you pay only a co-payment In-network allergy testing is covered in full Ongoing in-network allergy treatments are covered in full

When you visit an out-of-network physician or use an out-of-network facility for diagnostic procedures including allergy testing and treatment visits you pay the deductible and coinsurance plus any amount above Empirersquos allowed amount

Tips For Visiting Your Doctor x When you make your appointment confirm that the doctor is an Empire network provider and that heshe is

accepting new patients

x Arrange ahead of time to have pertinent medical records and test results sent to the doctor

x If the doctor sends you to an outside lab or radiologist for tests or X-rays call Member Services to confirm that the supplier is in Empirersquos network This will ensure that you receive maximum benefits

Ask about a second opinion anytime that you are unsure about surgery or a cancer diagnosis The specialist who provides the second or third opinion cannot perform the surgery To confirm a cancer diagnosis or course of treatment second or third opinions are paid at the in-network level even if you use an out-of-network specialist as long as your participating doctor provides a written referral to a non-participating specialist If you visit a non-participating specialist without a written referral you must pay the out-of-network deductible and coinsurance

WOMENrsquoS HEALTH AND CANCER RIGHTS OF ACT 1998

This federal law applies to almost all health care plans except Medicare Supplement and Medicare Risk plans as of plan years beginning on or after October 21 1998 The law imposes certain requirements on employee benefit plans and health insurers that provide medical and surgical benefits with respect to a mastectomy Specifically in the case of a participant or beneficiary who receives benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy the law requires coverage for

x Reconstruction of the breast on which the mastectomy has been performed x Surgery and reconstruction of the other breast to produce a symmetrical appearance x Prostheses and treatment of physical complications at all stages of mastectomy including lymphedemas

The coverage described above shall be provided in a manner determined in consultation with the attending physician and the patient This coverage is subject to all coverage terms and limitations (for example Deductibles and Coinsurance) consistent with those established for other benefits under the plan

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Consultation requested by the attending physician for advice on an illness or injury

This includes the Specialist e-Consultations Program If Your Participating Provider is in Our Cooperative Care program and is rendering primary care services to You he or she may request an electronic consultation with a Specialist to help evaluate Your condition or diagnosis The electronic consultation will be provided by a Participating Provider who has agreed to participate in Our ldquoeconsultationrdquo program and will be selected by Your Participating Provider in his or her clinical judgement The electronic consultation will be at no cost to You Your Participating Provider may consider the information provided by the Specialist in determining Your treatment The consultation will be conducted using electronic information and communication technologies such as secure web-based email fax andor exchange of electronic medical records The results may be documented in an electronic health record

x Diabetes supplies prescribed by an authorized provider Blood glucose monitors including monitors for the legally blind

18 wwwempirebluecom

Testing strips Insulin syringes injection aids cartridges for the legally blind insulin pumps and appurtenances and insulin

infusion devices Oral agents for controlling blood sugar Other equipment and supplies required by the New York State Health Department Data management systems

x Diabetes self-management education and diet information including

Education by a physician certified nurse practitioner or member of their staff frac34 At the time of diagnosis frac34 When the patientrsquos condition changes significantly frac34 When medically necessary

Education by a certified diabetes nurse educator certified nutritionist certified dietitian or registered dietitian when referred by a physician or certified nurse practitioner This benefit may be limited to a group setting when appropriate

Home visits for education when medically necessary

x Diagnosis and treatment of degenerative joint disease related to temporomandibular joint (TMJ) syndrome that is not a dental condition

x Diagnosis and treatment for Orthognathic surgery that is not a dental condition

x Medically necessary hearing examinations

x Foot care and orthotics associated with disease affecting the lower limbs such as severe diabetes which requires care from a podiatrist or physician

x Gender Reassignment Surgery and related non-cosmetic services

Lifetime Maximum benefit of $75000 for transgender surgery Counseling Services are covered These services will not count toward the $75000 Lifetime Maximum Benefit

x Cosmetic Services received in association with gender transformation are NOT covered including

x Reduction Thyroid Chondroplasty x Liposuction x Rhinoplasty x Facial Bone Reconstruction x Face Lift x Blepharoplasty x Voice Modification Surgery x Hair Removalhairplasty x Breast Augmentation

ONLINE VISITS

Your coverage includes online physician office visits Covered Services include a medical consultation using the internet via a webcam with online chat or voice functions Services are provided by board certified licensed primary care physicians Online visits are not for specialist care Common types of diagnoses and conditions treated online are cough fever headaches sore throat routine child health issues influenza upper respiratory infections sinusitis bronchitis and urinary tract infections when uncomplicated in nature Online visits are not meant for the following purposes

To get reports of normal lab or other test results To request an office appointment To ask billing insurance coverage or payment questions To ask for a referral to a specialist Doctor To request precertification for a benefit under your health Plan or To ask the physician to consult with another physician

You must have the following computer hardware in order for the online website to work properly USB or built in webcam (to enable two-way video during web conversations) and audio functionality To minimize audio feedback use a headset or headphones with a built-in microphone To begin the online visit log on to wwwlivehealthonlinecom and establish an

wwwempirebluecom 19

online account by providing some basic information about you and your insurance plan Before you connect to a Doctor you will be asked the kind of condition you want to discuss with the Doctor list your local pharmacy provide information for the credit card you want your cost share for the visit to be billed to agree to the terms of use and select an available physician If you are not in New York State when you seek an online visit you will need to check to be sure an online Doctor is available in the state you are in because online Doctors are not available in every state The visit with the physician will not start until you provide the above information and click ldquoconnectrdquo The visit will be documented in an electronic health record You may access your records and print them and may email or fax them to your primary care physician

CLINICAL TRIALS We Cover the routine patient costs for Your participation in an approved clinical trial and such coverage shall not be subject to Utilization Review if You are

x Eligible to participate in an approved clinical trial to treat either cancer or other life-threatening disease or condition and

x Referred by a Participating Provider who has concluded that Your participation in the approved clinical trial would be appropriate

All other clinical trials including when You do not have cancer or other life-threatening disease or condition may be subject to the Utilization Review and External Appeal sections of this booklet We do not Cover the costs of the investigational drugs or devices the costs of non-health services required for You to receive the treatment the costs of managing the research or costs that would not be covered under this benefit plan for non-investigational treatments provided in the clinical trial An ldquoapproved clinical trialrdquo means a phase I II III or IV clinical trial that is

x A federally funded or approved trial x Conducted under an investigational drug application reviewed by the federal Food and Drug Administration or x A drug trial that is exempt from having to make an investigational new drug application

Whatrsquos Not Covered The following medical services are not covered

x Routine foot care including care of corns bunions calluses toenails flat feet fallen arches weak feet and chronic foot strain

x Symptomatic complaints of the feet except capsular or bone surgery related to bunions and hammertoes x Orthotics for treatment of routine foot care x Routine hearing exams x Services such as laboratory X-ray and imaging and pharmacy services as required by law from a facility in which

the referring physician or hisher immediate family member has a financial interest or relationship x Services given by an unlicensed provider or performed outside the scope of the providerrsquos license

20 wwwempirebluecom

Emergency Care IF YOU NEED EMERGENCY CARE

Should you need emergency care your plan is there to cover you Emergency care is covered in the hospital emergency room

To be covered as emergency care the condition must be a medical or behavioral condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in

1 Placing the health of the person afflicted with such condition (or with respect to a pregnant woman the health of the woman or her unborn child) in serious jeopardy or in the case of a behavioral condition placing the health of such person or others in serious jeopardy

2 Serious impairment to such personrsquos bodily functions 3 Serious dysfunction of any bodily organ or part of such person or

4 Serious disfigurement of such person

Emergency Services are defined as a medical screening examination that is within the capability of the emergency department of a Hospital including ancillary services routinely available to the emergency department to evaluate an Emergency Condition and within the capabilities of the staff and facilities available at the Hospital such further medical examination and treatment as are required to stabilize the patient With respect to an emergency medical condition the term ldquoStabilizerdquo means to provide such medical treatment of the condition as may be necessary to assure within reasonable medical probability that no material deterioration of the condition is likely to result from or occur during the transfer of the patient from a facility or to deliver a newborn child (including the placenta)

Emergency Services are not subject to prior authorization requirements

Emergency Assistance 911 In an emergency call 911 for an ambulance or go directly to the nearest emergency room If possible go to the emergency room of a hospital in Empirersquos PPO network or the PPO network of another Blue Cross andor Blue Shield plan

You pay only a co-payment for a visit to an emergency room This co-payment is waived if you are admitted to the hospital within 24 hours If you make an emergency visit to your doctorrsquos office you pay the same co-payment as for an office visit

Benefits for treatment in a hospital emergency room are limited to the initial visit for an emergency condition A participating provider must provide all follow-up care in order to receive maximum benefits Remember You will need to show your Empire BlueCross BlueShield ID card when you arrive at the emergency room

Tips For Getting Emergency Care x If time permits speak to your physician to direct you to the best place for treatment x If you have an emergency while outside Empirersquos service area anywhere in the United States follow the same steps

described on the previous page If the hospital participates with another Blue Cross andor Blue Shield plan in the BlueCardpound PPO program your claim will be processed by the local plan Be sure to show your Empire ID card at the emergency room If the hospital does not participate in the BlueCard PPO program you will need to file a claim

x If you have an emergency outside of the United States and visit a hospital which participates in the BlueCardpound

Worldwide program simply show your Empire ID card The hospital will submit their bill through the BlueCard Worldwide Program If the hospital does not participate with the BlueCard Worldwide program you will need to file a claim

Please refer to the Health Management section for details regarding precertification requirements

wwwempirebluecom 21

Whatrsquos Not Covered These emergency services are not covered

x Use of the Emergency Room To treat routine ailments Because you have no regular physician Because it is late at night (and the need for treatment is not sudden and serious)

Emergency Air Ambulance We will provide in-network coverage for air ambulance services when needed to transport you to the nearest acute care hospital in connection with an emergency room or emergency inpatient admission or emergency outpatient care subject to cost sharing obligations when the following conditions are met

x Your medical condition requires immediate and rapid ambulance transportation and services cannot be provided by land ambulance due to great distances and the use of land transportation would pose an immediate threat to your health

x Services are covered to transport you from one acute care hospital to another only if the transferring hospital does not have adequate facilities to provide the medically necessary services needed for your treatment as determined by Empire and use of land ambulance would pose an immediate threat to your health

If Empire determines that the condition for coverage for air ambulance services has not been met but your condition did require transportation by land ambulance to the nearest acute care hospital Empire will only pay up to the maximum allowed amount that would be paid for land ambulance to that hospital You may be required to pay the difference between the maximum allowed amount and the total charges of an out-of-network provider

Please refer to the Health Management section for details regarding precertification requirements

Emergency Land Ambulance We will provide coverage for land ambulance transportation to the nearest acute care hospital in connection with emergency room care or emergency inpatient admission provided by an ambulance service when a prudent layperson possessing an average knowledge of medicine and health could reasonably expect the absence of such transportation to result in

x placing the memberrsquos health afflicted with a condition in serious jeopardy or for behavioral condition place the health of a member or others in serious jeopardy or

x serious impairment to a personrsquos bodily functions x serious dysfunction of any bodily organ or part of a person or x serious disfigurement to the member

Non-Emergency Ambulance Transportation

We cover non-emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance as appropriate) between facilities when the transport is any of the following

x From a non-participating Hospital to a participating Hospital x To a Hospital that provides a higher level of care that was not available at the original Hospital x To a more cost-effective Acute care Facility or x From an Acute Facility to a sub-Acute setting LimitationsTerms of Coverage

x We do not cover travel or transportation expenses unless connected to an Emergency Condition or due to a Facility transfer approved by us even though prescribed by a Physician

x We do not cover non-ambulance transportation such as ambulette van or taxi cab x Coverage for air ambulance related to an Emergency Condition or air ambulance related to non-emergency

transportation is provided when your medical condition is such that transportation by land ambulance is not appropriate and your medical condition requires immediate and rapid ambulance transportation that cannot be provided by land ambulance and one of the following is met The point of pick-up is inaccessible by land vehicle or Great distances or other obstacles (for example heavy traffic) prevent your timely transfer to the nearest Hospital

with appropriate facilities

22 wwwempirebluecom

Maternity Care IF YOU ARE HAVING A BABY

There are no out-of-pocket expenses for maternity and newborn care when you use in-network providers That means you do not need to pay a co-payment when you visit the obstetrician Furthermore routine tests related to pregnancy obstetrical care in the hospital or birthing center as well as routine newborn nursery care are all covered 100 in-network

For out-of-network maternity services you pay the deductible coinsurance and any amount above the maximum allowed amount Empirersquos reimbursements for the remaining balance may be consolidated in up to three installments as follows

x Two payments for prenatal care x One payment for delivery and post-natal care

Please refer to the Health Management section for details regarding precertification requirements Obstetrical care in the hospital or an in-network birthing center is covered up to 48 hours after a normal vaginal birth and 96 hours after a Cesarean section

NEWBORNSrsquo AND MOTHERSrsquo HEALTH PROTECTION ACT OF 1996 Group health plans and health insurance issuers generally may not under Federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section However Federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under Federal law require that a provider obtain authorization from the Program or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours as applicable) Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x One home care visit if the mother leaves earlier than the 48-hour (or 96-hour) limit The mother must request the visit from the hospital or a home health care agency within this timeframe (precertification is not required) The visit will take place within 24 hours after either the discharge or the time of the request whichever is later

x Services of a certified nurse-midwife affiliated with a licensed facility The nurse-midwifersquos services must be provided under the direction of a physician

x Parent education and assistance and training in breast or bottle feeding if available x Circumcision of newborn males x Special care for the baby if the baby stays in the hospital longer than the mother Call Empirersquos Medical Management

Program to precertify the hospital stay x Semi-private room

Whatrsquos Not Covered These maternity care services are not covered

x Days in hospital that are not medically necessary (beyond the 48-hour96-hour limits) x Services that are not medically necessary x Private room x Out-of-network birthing center facilities x Private duty nursing

REMEMBER Use a network obstetriciangynecologist to receive the lowest cost maternity care

wwwempirebluecom 23

Hospital Services IF YOU VISIT THE HOSPITAL

Your plan covers most of the cost of your medically necessary care when you stay at a network hospital for surgery or treatment of illness or injury When you use an out-of-network hospital or facility you pay the deductible and coinsurance plus any amount above Empirersquos maximum allowed amount

You are also covered for same-day (outpatient or ambulatory) hospital services such as chemotherapy radiation therapy cardiac rehabilitation and kidney dialysis Same-day surgical services or invasive diagnostic procedures are covered when they

x Are performed in a same-day or hospital outpatient surgical facility x Require the use of both surgical operating and postoperative recovery rooms x May require either local or general anesthesia x Do not require inpatient hospital admission because it is not appropriate or medically necessary and x Would justify an inpatient hospital admission in the absence of a same-day surgery program

Please refer to the Health Management section for details regarding precertification requirements

Tip For Getting Hospital Care x If you are having same-day surgery often the hospital or outpatient facility requires that someone meet you after the

surgery to take you home Ask about their policy and make arrangements for transportation before you go in for surgery

Inpatient And Outpatient Hospital Care

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations for both inpatient and outpatient (same-day) care

x Diagnostic X-rays and lab tests and other diagnostic tests such as EKGs EEGs or endoscopies x Oxygen and other inhalation therapeutic services and supplies and anesthesia (including equipment for administration x Anesthesiologist including one consultation before surgery and services during and after surgery x Blood and blood derivatives for emergency care same-day surgery or medically necessary conditions such as

treatment for hemophilia x MRIsMRAs PETCAT scans and nuclear cardiology services

Please refer to the Health Management section for details regarding precertification requirements

Inpatient Hospital Care

Whatrsquos Covered Following are additional covered services for inpatient care

x Semi-private room and board when The patient is under the care of a physician and A hospital stay is medically necessary

x Coverage is for unlimited days unless otherwise specified x Operating and recovery rooms x Special diet and nutritional services while in the hospital x Cardiac care unit x Services of a licensed physician or surgeon employed by the hospital x Care related to surgery x Breast cancer surgery (lumpectomy mastectomy) including

Reconstruction following surgery Surgery on the other breast to produce a

symmetrical appearance

Prostheses Treatment of physical complications at any stage of a

mastectomy including lymphedemas The patient has the right to decide in consultation with the physician the length of hospital stay following mastectomy surgery

x Use of cardiographic equipment x Drugs dressings and other medically necessary supplies x Social psychological and pastoral services x Reconstructive surgery associated with injuries unrelated to cosmetic surgery x Reconstructive surgery for a functional defect which is present from birth x Physical occupational speech and vision therapy including facilities services supplies and equipment x Facilities services supplies and equipment related to medically necessary medical care x Residential treatment services are not covered

Please refer to the Health Management section for details regarding precertification requirements

24 wwwempirebluecom

Outpatient Hospital Care

Whatrsquos Covered Following are additional covered services for same-day care

x Same-day and hospital outpatient surgical facilities x Surgeons x Surgical assistant if

None is available in the hospital or facility where the surgery is performed and The surgical assistant is not a hospital employee

x Chemotherapy and radiation therapy including medications in a hospital outpatient department doctorrsquos office or facility Medications that are part of outpatient hospital treatment are covered if they are prescribed by the hospital and filled by the hospital pharmacy

x Kidney dialysis treatment (including hemodialysis and peritoneal dialysis) is covered in the following settings until the patient becomes eligible for end-stage renal disease dialysis benefits under Medicare At home when provided supervised and arranged by a physician and the patient has registered with an approved

kidney disease treatment center (professional assistance to perform dialysis and any furniture electrical plumbing or other fixtures needed in the home to permit home dialysis treatment are not covered

In a hospital-based or free-standing facility See ldquohospitalfacilityrdquo in the Definitions section

Please refer to the Health Management section for details regarding precertification requirements

Inpatient Hospital Care

Whatrsquos Not Covered These inpatient services are not covered

x Private duty nursing x Private room If you use a private room you need to pay the difference between the cost for the private room and the

hospitalrsquos average charge for a semiprivate room The additional cost cannot be applied to your deductible or coinsurance

x Diagnostic inpatient stays unless connected with specific symptoms that if not treated on an inpatient basis could result in serious bodily harm or risk to life

x Services performed in the following Nursing or convalescent homes Institutions primarily for rest or for the aged Rehabilitation facilities (except for physical therapy)

Spas Sanitariums Infirmaries at schools colleges or camps

x Any part of a hospital stay that is primarily custodial x Elective cosmetic surgery or any related complications x Hospital services received in clinic settings that do not meet Empirersquos definition of a hospital or other covered facility

See ldquohospitalfacilityrdquo in the Details and Definitions section

Outpatient Hospital Care

Whatrsquos Not Covered These outpatient services are not covered

x Same-day surgery not precertified as medically necessary by Empirersquos Medical Management Program x Routine medical care including but not limited to

Inoculation or vaccination Drug administration or injection excluding chemotherapy

x Collection or storage of your own blood blood products semen or bone marrow

wwwempirebluecom 25

Durable Medical Equipment and Supplies IF YOU NEED EQUIPMENT OR MEDICAL SUPPLIES

Your plan covers the cost of medically necessary prosthetics orthotics and durable medical equipment from network suppliers only In-network benefits and plan maximums are shown in Your Benefits at a Glance section Out-of-network benefits are not available

Please refer to the Health Management section for details regarding precertification requirements

An Empire network supplier may not bill you for covered services If you receive a bill from one of these providers contact Member Services at 1-855-519-9537

Disposable medical supplies such as syringes are covered up to the maximum allowed amount whether you obtain them in- or out-of-network

Coverage for enteral formulas or other dietary supplements for certain severe conditions is available both in- and out-of network If you have prescription drug coverage with Empirersquos pharmacy program you may order these formulas or supplements through Empirersquos pharmacy program Whatrsquos Covered Covered services are listed in Your Benefits At A Glance section Following are additional covered services and limitations

x Prosthetics orthotics and durable medical equipment from network suppliers when prescribed by a doctor including Artificial arms legs eyes ears nose larynx and external breast prostheses Prescription lenses if organic lens is lacking Supportive devices essential to the use of an artificial limb Corrective braces Wheelchairs hospital-type beds oxygen equipment sleep apnea monitors

x Rental (or purchase when more economical) of medically necessary durable medical equipment x Replacement of covered medical equipment because of wear damage or change in patientrsquos need when ordered by a

physician x Reasonable cost of repairs and maintenance for covered medical equipment x Enteral formulas with a written order from a physician or other licensed health care provider The order must

state that The formula is medically necessary and effective and Without the formula the patient would become malnourished suffer from serious physical disorders or die

x Modified solid food products for the treatment of certain inherited diseases A physician or other licensed healthcare provider must provide a written order

x Hearing aids and the examination for their fitting Please refer to the Health Management section for details regarding precertification requirements

Whatrsquos Not Covered The following equipment is not covered x Air conditioners or purifiers x Humidifiers or dehumidifiers x Exercise equipment

x Swimming pools x False teeth

26 wwwempirebluecom

Skilled Nursing and Hospice Care IF YOU NEED SKILLED NURSING OR HOSPICE CARE

You receive coverage through Empirersquos PPO for inpatient care in a skilled nursing facility or hospice Benefits are available for network facilities only Benefits and plan maximums are shown in Your Benefits at a Glance section

Please refer to the Health Management section for details regarding precertification requirements

Skilled Nursing Care

Whatrsquos Covered You are covered for inpatient care in a network skilled nursing facility if you need medical care nursing care or rehabilitation services The number of covered days is listed in Your Benefits at a Glance section Prior hospitalization is not required in order to be eligible for benefits Services are covered if

x The doctor provides A referral and written treatment plan A projected length of stay

An explanation of the services the patient needs and The intended benefits of care

x Care is under the direct supervision of a physician registered nurse (RN) physical therapist or other healthcare professional

Whatrsquos Not Covered The following skilled nursing care services are not covered

x Skilled nursing facility care that primarily Gives assistance with daily living activities Is for rest or for the aged Treats drug addiction or alcoholism

Convalescent care Sanitarium-type care Rest cures

Hospice Care Empire covers unlimited days of hospice care once in a covered personrsquos lifetime Hospices provide medical and supportive care to patients who have been certified by their physician as having a life expectancy of twelve (12) months or less Hospice care can be provided in a hospice in the hospice area of a network hospital or at home as long as it is provided by a network hospice agency

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Hospice care services including Up to 12 hours of intermittent care each day by a registered nurse (RN) or licensed practical nurse (LPN) Medical care given by the hospice doctor Drugs and medications prescribed by the patientrsquos doctor that are not experimental and are approved for use by

the most recent Physiciansrsquo Desk Reference Physical occupational speech and respiratory therapy when required for control of symptoms Laboratory tests X-rays chemotherapy and radiation therapy Social and counseling services for the patientrsquos family including bereavement counseling visits until one year

after death Transportation between home and hospital or hospice when medically necessary Medical supplies and rental of durable medical equipment Up to 14 hours of respite care in any week

Tips for Receiving Skilled Nursing and Hospice Care x To learn more about a skilled nursing facility ask your doctor or caseworker to see the Health Facilities directory x For hospice care in your home ask whether the same caregiver will come each day or whether you will see someone

new each time What recourse do you have if you are not comfortable with the caregiver

wwwempirebluecom 27

Home Health Care IF YOU NEED HOME HEALTH CARE

Home health care can be an alternative to an extended stay in a hospital or a stay in a skilled nursing facility You receive coverage when you use an in-network provider For out-of-network home health care you pay coinsurance only (the deductible does not apply) Out-of-network agencies must be certified by New York State or have comparable certification from another state Benefits and plan maximums are shown in Your Benefits at a Glance section

Home infusion therapy a service sometimes provided during home health care visits is only available in-network An Empire network home health care agency or home infusion supplier cannot bill you for covered services If you receive a bill from one of these providers contact Member Services at 1-855-519-9537 Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Up to 200 home health care visits per year combined in- and out-of-network A visit is defined as up to four hours of care Care can be given for up to 12 hours a day (three visits) Your physician must certify home health care as medically necessary and approve a written treatment plan

x Home health care services include Part-time services by a registered nurse (RN) or licensed practical nurse (LPN) Part-time home health aide services (skilled nursing care) Physical speech or occupational therapy if restorative Medications medical equipment and supplies prescribed by a doctor Laboratory tests

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Up to 200 home health care visits per year combined in- and out-of-network A visit is defined as up to four hours of care Care can be given for up to 12 hours a day (three visits) Your physician must certify home health care as medically necessary and approve a written treatment plan

x Home health care services include Part-time services by a registered nurse (RN) or licensed practical nurse (LPN) Part-time home health aide services (skilled nursing care) Physical speech or occupational therapy if restorative Medications medical equipment and supplies prescribed by a doctor Laboratory tests

Whatrsquos Not Covered The following home health care services are not covered

x Custodial services including bathing feeding changing or other services that do not require skilled care x Out-of-network home infusion therapy

28 wwwempirebluecom

Physical Occupational Speech or Vision Therapy IF YOU NEED THERAPY

You receive benefits through Empirersquos plan for physical occupational speech and vision therapy Outpatient physical occupational speech and vision therapy services are available in-network and out-of-network Inpatient physical therapy can be in-network or out-of-network

Please refer to the Health Management section for details regarding precertification requirements

Tip for Receiving Therapy x Ask for exercises you can do at home that will help you get better faster

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Physical therapy physical medicine or rehabilitation services or any combination of these on an inpatient or outpatient basis up to the plan maximums if Prescribed by a physician Designed to improve or restore physical functioning within a reasonable period of time and Approved by Empirersquos Medical Management Program (for in-network physical therapy only) Designed to improve or restore physical functioning within a reasonable period of time

Outpatient care must be given at home in a therapistrsquos office or in an outpatient facility by an in-network provider inpatient therapy must be short-term

x Occupational speech or vision therapy or any combination of these on an outpatient basis up to the plan maximums if Prescribed by a physician or in conjunction with a physicianrsquos services Given by skilled medical personnel at home in a therapistrsquos office or in an outpatient facility Performed by a licensed speechlanguage pathologist or audiologist

Whatrsquos Not Covered The following therapy services are not covered

x Therapy to maintain or prevent deterioration of the patientrsquos current physical abilities x Tests evaluations or diagnoses received within the 12 months prior to the doctorrsquos referral or order for occupational

speech or vision therapy

wwwempirebluecom 29

Behavioral Healthcare IF YOU NEED BEHAVIORAL HEALTHCARE

At Empire we realize that your mental health is as important as your physical health Thatrsquos why we include behavioral healthcare benefits at little out-of-pocket cost Your behavioral healthcare benefits cover outpatient treatment for alcohol or substance abuse both in-network and out-of-network and inpatient detoxification in-network and out-of-network Inpatient alcohol and substance abuse rehabilitation in a facility is covered in-network and out-of-network Mental healthcare is covered on an inpatient basis in-network and out-of-network and on an outpatient basis in-network and out-of-network

Please note that with the exception of outpatient alcohol and substance abuse treatment the coinsurance that you pay for out-of-network behavioral healthcare services will not count toward reaching your annual out-of-pocket limit

Please refer to the Health Management section for details regarding precertification requirements

Mental Health Care

Whatrsquos Covered In addition to the services listed in Your Benefits at a Glance section the following mental health care service is covered

x Electroconvulsive therapy for treatment of mental or behavioral disorders if precertified by Behavioral Healthcare Management

x Care from psychiatrists psychologists nurse practitioners or licensed clinical social workers providing psychiatric or psychological services within the scope of their practice including the diagnosis and treatment of mental and behavioral disorders Social workers must be licensed by the New York State Education Department or a comparable organization in another state and have three years of post-degree supervised experience in psychotherapy and an additional three years of post-licensure supervised experience in psychotherapy

x Treatment in a New York State Health Department-designated Comprehensive Care Center for Eating Disorders pursuant to Article 27-J of the New York State Public Health Law

x We Cover inpatient mental health care services relating to the diagnosis and treatment of mental nervous and emotional disorders received at Facilities that provide room and board charges

Whatrsquos Not Covered The following mental health care services are not covered

x Care that is not medically necessary x Out-of-network inpatient mental health care at a facility that is not an acute care general hospital x Residential treatment services

Treatment for Alcohol or Substance Abuse

Whatrsquos Covered In addition to the services listed in Your Benefits at a Glance section the following services are covered

x Family counseling services at an outpatient treatment facility These can take place before the patientrsquos treatment begins Any family member covered by the plan may receive one counseling visit per day

x Visits for family counseling are deducted from the 60 visits available for outpatient treatment x Out-of-network outpatient treatment at a facility that

Has New York State certification from the Office of Alcoholism and Substance Abuse Services Is approved by the Joint Commission on the Accreditation of Health Care Organizations if out of state The

program must offer services appropriate to the patientrsquos diagnosis

Whatrsquos Not Covered The following alcohol and substance abuse treatment services are not covered

x Out-of-network outpatient alcohol or substance abuse treatment at a facility that does not meet Empirersquos certification requirements as stated above

x Care that is not medically necessary x Out-of-network inpatient alcohol or substance abuse rehabilitation at a facility that is not an acute care general

hospital x Out-of-network inpatient detoxification at a facility that is not an acute care general hospital x Residential treatment services

30 wwwempirebluecom

Empirersquos Pharmacy Program YOUR PHARMACY BENEFITS PROGRAM

Empire understands that filling prescriptions can be costly To help reduce your costs Empire offers the pharmacy program Your Empire pharmacy program covers most drugs as long as they have been prescribed by a physician and approved by the Federal Drug Administration (FDA) You can choose whether to fill your prescription at a network pharmacy or through the mail order program

FILLING A PRESCRIPTION When you have a prescription filled you must pay the pharmacy the cost share amount for each separate prescription or refill We will pay the pharmacy directly for the remainder of the cost of the prescription or refill The Maximum Allowed Amount for covered Prescription Drugs is the amount determined by us using prescription drug cost information provided by the Pharmacy Benefits Manager (PBM) The amount of the cost share for your prescription drug coverage is listed in Your Benefits At A Glance chart

EMPIRErsquoS DRUG FORMULARY Empire uses a preferred drug formulary which is a list of generic and preferred brand drugs that is distributed to participating pharmacies and providers and is subject to periodic review and modification by Us Your doctor is encouraged to prescribe generic-equivalent drugs as appropriate when possible and to prescribe drugs from the preferred drug formulary when prescribing brand-name drugs

The Preferred Formulary has three tiers

Tier 1 drugs generally have the lowest Cost Share This tier contains preferred medications that are generic single source brand drugs or multi-source brand drugs Tier 2 drugs generally have a higher Cost Share than those in Tier 1 This tier contains preferred medications that are generic single source brand drugs or multi-source brand drugs Tier 3 drugs generally have a higher Cost Share than those on Tier 2 This tier contains non-preferred medications that are generic single source brand drugs or multi-source brand drugs

Preferred Generics For most Prescription Drugs You pay only the Cost-Sharing in the Your Benefits at a Glance section of the booklet An additional charge called an ldquoancillary chargerdquo may apply to some Prescription Drugs when a Prescription Drug on a higher tier is dispensed at You or Your Providerrsquos request and Our formulary includes a chemically equivalent Prescription Drug is available on a lower tier You will have to pay the difference between the full cost of the Prescription Drug on the higher tier and the cost of the Prescription Drug on the lower tier The cost difference is not Covered and must be paid by You in addition to the lower tier Cost-Sharing Your Cost-Sharing will never exceed the Usual and Customary Charge of the Prescription Drug Note Prescription Drugs will always be dispensed as ordered by your Doctor You may ask for or your Doctor may order the Brand Name Drug However if a Generic Drug is available you will have to pay the difference in the cost between the Generic and Brand Name Drug as well as your Tier 1 Copayment Coinsurance By law Generic and Brand Name Drugs must meet the same standards for safety strength and effectiveness Using generics generally saves money yet gives the same quality For certain higher cost generic drugs we reserve the right in our sole discretion to make an exception and not require you to pay the difference in cost between the Generic and Brand Name Drug

wwwempirebluecom 31

You are responsible for paying the full cost (the amount the pharmacy charges You) for any non-Covered Prescription Drug and Our contracted rates (Our Prescription Drug Cost) will not be available to You Tier Assignment Process Empirersquos Pharmacy and Therapeutics (PampT) Committee consists of health care professionals including nurses pharmacists and physicians The purpose of this committee is to assist in determining clinical appropriateness of drugs determining the tier assignments of drugs and advising on programs designed to help improve delivery of care Such programs may include drug utilization programs prior authorization criteria therapeutic conversion programs and drug profiling initiatives The determination of tiers is made based upon clinical decisions provided by the PampT Committee and where appropriate the cost of the Drug relative to other Drugs in its therapeutic class or used to treat the same or similar condition the availability of over-the-counter alternatives and where appropriate certain clinical economic factors Empire retains the right to determine coverage for dosage formulations in terms of covered dosage administration methods (for example by mouth injections topical or inhaled) and may cover one form of administration and exclude or place other forms of administration on another Tier The formulary and procedures are made available to all network providers at least once a year or sooner if there are changes

SPECIALTY DRUGS You or your Physician are required to order your Specialty Drugs directly from a Network Specialty Pharmacy ldquoSpecialty Drugsrdquo are prescription drugs which

x Are approved to treat limited patient populations indications or conditions x Are normally injected infused or require close monitoring by a physician or clinically trained individual or x Have limited availability special dispensing and delivery requirements andor require additional patient support any

or all of which make the drug difficult to obtain through traditional pharmacies

Network Specialty Pharmacies may fill both retail and mail service Specialty Drug prescription orders up to a thirty (30) day supply for retail and mail service and subject to the applicable Deductible Coinsurance or Copayment shown in the Your Benefits At A Glance chart

Network Specialty Pharmacies have dedicated patient care coordinators to help you obtain prior authorization if applicable manage your condition and offer toll-free twenty-four hour access to nurses and registered pharmacists to answer questions regarding your medications

You may obtain a list of the Network Specialty Pharmacies and covered Specialty Drugs by calling the Customer Service telephone number on the back of your ID card or review the lists on our website at wwwempirebluecom select ldquoPharmacyrdquo under the ldquoPlans and Benefitsrdquo tab of the ldquoMember Homerdquo page

In addition certain drugs that must be administered by a physician or other authorized practitioner are required to be ordered from our Network Specialty Pharmacy in order to be covered as a medical benefit If you require one of these drugs your physician or other treating practitioner will order the drug from the required pharmacy You will not be required to fill a prescription for this category of drug

SPECIAL PROGRAMS From time to time we may initiate various programs to encourage Covered Persons to utilize more cost-effective or clinically-effective drugs including but not limited to generic drugs mail order drugs over the counter (OTC) or preferred products Such programs may involve reducing or waiving Copayments or Coinsurance for certain drugs or preferred products for a limited period of time

REMEMBER Benefits are only available for prescriptions filled at network pharmacies or through Empirersquos mail order

NETWORK PHARMACY You must fill a prescription at an Empire network pharmacy for up to a 34-day supply of FDA-approved drugs if prescribed by a physician or other licensed provider Empirersquos pharmacy program offers

x Low cost You can receive up to a 34-day supply for each drug for a single co-payment x Convenience You must present your Empire ID card to the pharmacist along with your prescription Thatrsquos all you

need to get the cost advantages of this program x No claim forms Under your policy guidelines paper claims cannot be submitted The pharmacist must submit your

claim when you fill the prescription

32 wwwempirebluecom

Tip for Using a Network Pharmacy To locate a network pharmacy check the list of national chain pharmacies you received with your ID card For information about network pharmacies that are not a part of a national chain log on to wwwempirebluecom and click on the Rx icon on your home page or call Empirersquos pharmacy program at 1-800-342-9816 You can also call when you are away from home for the name and location of the nearest participating pharmacy

REMEMBER A pharmacist is not required to fill a prescription that in the pharmacistrsquos professional judgment should not be filled

SAVE MONEY WITH EMPIRErsquoS MAIL ORDER PRESCRIPTIONS Certain Prescription Drugs may be ordered through our mail order pharmacy You can reduce your drug co-payments by using Empirersquos pharmacy mail order because you can receive up to a 90-day (three-month) supply of your medication on a single prescription for only one co-payment This service is ideal for members who take the same medication on an on-going basis The same prescriptions filled at a participating pharmacy cost three co-payments for a three-month supply of medicationmdashone co-payment for each 34-day supply In addition Empire waives drug deductibles when you use the mail order Deductibles still apply if you fill your prescriptions at a pharmacy Home Delivery for Maintenance Medications ndash If you are taking a Maintenance Medication you may get the first 30-day supply and two 30-day refills of the same Maintenance Medication at your local Retail Pharmacy You must then contact the Home Delivery Pharmacy and tell them if you would like to keep getting your 30-day supply of Maintenance Medications from your local Retail Pharmacy or if you would like to use the Home Delivery Pharmacy You will have to pay the full retail cost of any Maintenance Medication you get without registering your choice through the Home Delivery Pharmacy You can tell us your choice by phone at the number on the back of your ID Card or by visiting our website

How to Order Your Prescription by Mail x Ask your doctor to write a prescription for each of your medication(s) that covers a 90-day supply as well as three

refills (Example If you take 2 pills per day the prescription should be written for 180 pills plus three refills) x Complete the mail order form you received in the mail with your ID card(s) You can get additional forms by going

to wwwempirebluecom or calling Empirersquos pharmacy program at the number on the back of your member ID card x Place your order for a refill at least three weeks before your current supply will run out x You will receive your filled prescription at your home within 14 working days postage paid If you prefer you can

also choose faster shipping for an additional fee

Tips for Using Mail Order The first time you fill a prescription through mail order ask your physician for a second prescription for a four-week supply You can fill the second prescription at a local pharmacy so you have the medication until the mail order is processed

MANAGE YOUR PHARMACY PLAN ONLINE Taking care of your pharmacy needs is easier than ever with Empirersquos online pharmacy If yoursquore registered for Online Member Services just go to wwwempirebluecom where you can

x Search Empirersquos drug formulary for a particular drug (by name or therapeutic category) x Locate a participating retail pharmacy near where you live or work x Order prescription refills through the mail order program x Research usage instructions drug interactions and side effects for thousands of medications

Simply log on to our web site and access your own personal secure home page Click on ldquoMy Pharmacy Planrdquo which is right next to the Rx symbol under ldquoYour Health Planrdquo

Empirersquos Pharmacy Program Customer Service 1-800-342-9816 Whatrsquos Covered The following prescription drugs are covered x Insulin and self-administered injectables x Diabetic supplies x Enteral formulas for home use that are medically

necessary and proven effective for the specific disease when prescribed by a written order by a physician or other health care provider licensed to prescribe under applicable law

x Nutritional supplements when medically necessary and proven effective for treatment

x Contraceptive drugs or devices and diaphragms x Bone mineral density drugs and devices x Refills for up to one year from the date of the original

prescription if authorized by the physician and indicated on the prescription

x Smoking cessation products by prescription only

wwwempirebluecom 33

Whatrsquos Not Covered The following items are not covered x Drugs or devices that do not require a prescription or are available over the counter except insulin and diabetic supplies x Devices of any type such as therapeutic devices IUDrsquos artificial appliances hypodermic needles syringes or similar

devices except where specifically covered and except for bone density testing and treatment devices x Charges or fees for drug administration or injection x Vitamins that by law do not require a prescription x Investigational or experimental drugs (ie medications used for experiments andor dosage levels determined by Empire

to be experimental) Refer to the Exclusions and Limitations Section and also the Complaints Appeals and Grievances Section

34 wwwempirebluecom

x Drugs received while in a hospital nursing home or other facility (covered under medical plan as indicated) x Appetite suppressants unless medically necessary x Compounded medications with no ingredients that require a prescription x Medications for cosmetic purposes only x Medications not approved by the FDA unless otherwise required by law (ie drugs that have been prescribed for the

treatment of a type of cancer for which the drug has not been approved by the FDA and not considered investigational or experimental)

x Replacement of lost stolen or damaged prescription medications x The cost for medication in excess of plan limits x Refills not dispensed in accordance with the prescription x Refills beyond one year from the original prescription date

wwwempirebluecom 35

SCHEDULE A1

Drugs Subject to Prior Authorization

Drug Class Prescription Drug

Pain Relief Abstral Arthritis Actemra Pain Relief Actiq Pulmonary Arterial Hypertension Adcirca Cancer Treatment Afinitor Psoriasis Amevive Multiple Sclerosis Ampyra Hormonal Therapy Androderm Hormonal Therapy Androgel Blood Builder Aranesp Hormonal Therapy Arixion Cancer Treatment Avastin Cervical DystoniaSpasticity Botox Immune SystemImmune Globulin Carimune NF Gaucherrsquos Disease Ceredase Gaucherrsquos Disease Cerezyme ArthritisCrohns Disease Cimzia Cervical DystoniaSpasticity Dysport Cancer Treatment Eligard ArthritisPsoriasis Enbrel Blood Builder Epogen Cancer Treatment Erbitux Arthritis Euflexxa Pain Relief Fentora Immune SystemImmune Globulin Flebogamma Pulmonary Arterial Hypertension Flolan Osteporosis Forteo Hormonal Therapy Fortesta Immune SystemImmune Globulin Gamastan Immune SystemImmune Globulin Gammagard liquid SD Immune SystemImmune Globulin Gamunex Multiple Sclerosis Gilenya Cancer Treatment Gleevac Cancer Treatment Herceptin ArthritisCrohnsPsoriasis Humira Arthritis Hyalgan Immune Deficiency Increlex Hepatitis Infergen Hepatitis Intron-A Arthritis Kineret Infection Prevention and Treatment Lamisil Blood Builder Leukine Cancer TreatmentInfertility Leuprolide Macular Degeneration Lucentis Endometriosis InfertilityCancer Lupron Depot SeizuresFibromyalgiaNerve Pain Lyrica Macular Degeneration Macugen Cervical DystoniaSpasticity Myobloc Blood Builder Neulasta Blood Builder Neumega Blood Builder Neupogen Cancer Treatment Nexavar

36 wwwempirebluecom

SCHEDULE A1 (continued)

Drugs Subject to Prior Authorization

Drug Class Prescription Drug

Excessive Sleepiness Nuvigil Immune SystemImmune Globulin Octagam Cancer Treatment Oforta Pain Relief Onsolis Arthritis Orencia Arthritis Orthovisc Immune SystemImmune Globulin Panglobulin Hepatitis Pegasys Hepatitis Peg-Intron Infection Prevention and Treatment Penlac Immune SystemImmune Globulin Polygam SD Immune SystemImmune Globulin Privigen Blood Builder Procrit Osteporosis Prolia Excessive Sleepiness Provigil Infection Prevention and Treatment Qualaquin ArthritisCrohnsPsoriasis Remicade Pulmonary Arterial Hypertension Remodulin Pulmonary Arterial Hypertension Revatio Cancer Treatment Revlimid Cancer Treatment Rituxan Hepatitis Roferon-A ArthritisPsoriasis Simponi Excessive Sleepiness Sporanox Infection Prevention and Treatment Sprycel ArthritisCrohnsPsoriasis Stelara Opiod Dependence Suboxone Arthritis Supartz Precocious Puberty Supprelin LA Cancer Treatment Sutent RSV Prevention Synagis Precocious PubertyEndometriosis Synarel Arthritis Synvisc Arthritis Synvisc One Cancer Treatment Tarceva Cancer Treatment Targretin Cancer Treatment Tasigna Cancer Treatment Temodar Hormonal Therapy Testim Cancer Treatment Thalomid Cancer Treatment Trelstar Depot LA Cancer Treatment Tykerb Pulmonary Arterial Hypertension Tyvaso Cancer Treatment Vantas Implant Cancer Treatment Vectibix Pulmonary Arterial Hypertension Ventavis Infection Prevention and Treatment Vfend Immune SystemImmune Globulin Vivaglobin Addiction Treatment Vivitrol Cancer Treatment Votrient Gaucherrsquos Disease Vpriv Cancer Treatment Xeloda

wwwempirebluecom 37

SCHEDULE A1 (continued)

Drugs Subject to Prior Authorization

Drug Class Prescription Drug

Huntingtons Disease Xenazine Bone FracturePain Due to Cancer Xgeva Arthritis Xiaflex Antibiotic Xifaxan Asthma Xolair Gaucherrsquos Disease Zavesca Cancer Treatment Zoladex Cancer Treatment Zolinza Infection Prevention and Treatment Zyvox

38 wwwempirebluecom

SCHEDULE A2

Step Therapy Drugs Subject to Prior Authorization

Drug Class Prescription Drug

Proton Pump Inhibitor Aciphex Antiacne Adoxa Antiallergy-opthalmic Alamast Non-Sedating Antihistamine Allegra ODT Suspension D Antiallergy-opthalmic Alocril Antiallergy-opthalmic Alomide Antihyperlipidemic Altoprev SedativeHypnotics Ambien CR CNS Stimulant Amphetamine Salt Combo Hypoglycemics Apidra Non-Steroidal Antiinflammatories Arthrotec Diabetes Avandament Diabetes Avandaryl Diabetes Avandia Migraine Medication Axert Diabetes Blood Glucose MetersStrips Nasal Steroids Beconase AQ Antiacne - Topical Benzaclin Multiple Sclerosis Betaseron Osteoporosis Boniva Ovulatory Stimulants Bravelle Hypoglycemics Byetta Non-Steroidal Antiinflammatories Celebrex Non-Sedating Antihistamine Clarinex-D Non-Sedating Antihistamine Clarinex Suspension Proton Pump Inhibitor Dexilant Antiacne Doryx SedativeHypnotics Edluar Antiallergy-opthalmic Elestat Dermatological Agent Elidel Antiallergy-opthalmic Emadine Overactive Bladder Agents Enablex Multiple Sclerosis Extavia Analgesics Flector Nasal Steroids Flunisolide Nasal Spray Overactive Bladder Agents Gelnique Ovulatory Stimulants Gonal-F Proton Pump Inhibitors Kapidex Antihyperlipidemic Lescol XL Antihypertensive Letairis Antihyperlipidemic Livalo Antiacne Minocin Nasal Steroids Nasacort AQ Nasal Steroids Nasarel Nasal Steroids Omnaris Antiallergy-opthalmic Optivar Overactive Bladder Agents Oxytrol Proton Pump Inhibitors pantaprazole Proton Pump Inhibitors Prilosec Proton Pump Inhibitors Prevacid Proton Pump Inhibitors Protonix Dermatological Agent Protopic

wwwempirebluecom 39

SCHEDULE A2

Step Therapy Drugs Subject to Prior Authorization (continued)

x

Drug Class Prescription Drug

Migraine Medication Relpax Nasal Steroids Rhinocort Aqua SedativeHypnotics Rozerem Antiacne Solodyn Overactive Bladder Agents Sanctura SedativeHypnotics Sonata Migraine Medication Sumavel DosePro Migraine Medication Treximet Gout Medications Uloric Hypoglycemics Victoza Antihyperlipidemics Vytorin Non-Sedating Antihistamine Xyzal Syrup Proton Pump Inhibitors Zegerid Antihyperlipidemics Zetia Skin Condition Ziana Sleep Aid Zolpimist

40 wwwempirebluecom

Exclusions and Limitations EXCLUSIONS

In addition to services mentioned under ldquoWhatrsquos Not Coveredrdquo in the prior sections your plan does not cover the following

Dental Services x Dental services including but not limited to

Cavities and extractions Care of gums Bones supporting the teeth or periodontal

abscess Orthodontia

False teeth Treatment of TMJ that is dental in nature Orthognathic surgery that is dental in nature

However your plan does cover

x Surgical removal of impacted teeth x Treatment of sound natural teeth injured by accident if treated within 12 months of the injury

ExperimentalInvestigational Treatments x Technology treatments procedures drugs biological products or medical devices that in Empirersquos judgment are

Experimental or investigative Obsolete or ineffective x Any hospitalization in connection with experimental or investigational treatments ldquoExperimentalrdquo or ldquoinvestigativerdquo

means that for the particular diagnosis or treatment of the covered personrsquos condition the treatment is Not of proven benefit Not generally recognized by the medical community (as reflected in published medical literature)

Government approval of a specific technology or treatment does not necessarily prove that it is appropriate or effective for a particular diagnosis or treatment of a covered personrsquos condition Empire may require that any or all of the following criteria be met to determine whether a technology treatment procedure biological product medical device or drug is experimental investigative obsolete or ineffective

x (FDA Approval) for the patientrsquos particular diagnosis or condition except for certain drugs prescribed for the treatment of cancer Once the FDA approves use of a medical device drug or biological product for a particular diagnosis or condition use for another diagnosis or condition may require that additional criteria be met

x Published peer review medical literature must conclude that the technology has a definite positive effect on health outcomes

x Published evidence must show that over time the treatment improves health outcomes (ie the beneficial effects outweigh any harmful effects)

x Published proof must show that the treatment at the least improves health outcomes or that it can be used in appropriate medical situations where the established treatment cannot be used Published proof must show that the treatment improves health outcomes in standard medical practice not just in an experimental laboratory setting

However your plan will cover an experimental or investigational treatment approved by an External Appeal agent certified by the state Refer to the Complaints Appeals and Grievances Section

Government Services x Services covered under government programs except Medicaid or where otherwise noted x Government hospital services except

Specific services covered in a special agreement between Empire and a government hospital United States Veteransrsquo Administration or Department of Defense Hospitals except services in connection with

a service-related disability In an emergency Empire will provide benefits until the government hospital can safely transfer the patient to a participating hospital

Home Care x Services performed at home except for those services specifically noted elsewhere in this Guide as available either at

home or as an emergency

wwwempirebluecom 41

Inappropriate Billing x Services usually given without charge even if charges are billed x Services performed by hospital or institutional staff which are billed separately from other hospital or institutional

services except as specified

Medically Unnecessary Services x Services treatment or supplies not medically necessary in Empirersquos judgment See Definitions section for more

information

Not Medically Necessary Transgender Surgery x Surgery andor treatment for gender change that does not meet our medical criteria for medical necessity

Prescription Drugs x All over the counter drugs vitamins appetite suppressants or any other type of medication unless specifically

indicated

Services Provided by a Family Member x We do not Cover services performed by a member of the covered personrsquos immediate family ldquoImmediate familyrdquo

shall mean a child spouse mother father sister or brother of You or Your Spouse

SterilizationReproductive Technologies x Reversal of sterilization x Assisted reproductive technologies including but not limited to

In-vitro fertilization Artificial insemination

Gamete and zygote intrafallopian tube transfer Intracytoplasmic sperm injection

Travel x Travel even if associated with treatment and recommended by a doctor

Vision Care x Eyeglasses contact lenses [and the examination for their fitting] except following cataract surgery unless

specifically indicated

War x Services for illness or injury received as a result of war

Workersrsquo Compensation x Services covered under Workersrsquo Compensation no-fault automobile insurance andor services covered by similar

statutory programs

LIMITATION AS INDEPENDENT CONTRACTOR The relationship between Empire BlueCross BlueShield and hospitals facilities or providers is that of independent contractors Nothing in this contract shall be deemed to create between Empire and any hospital facility or provider (or agent or employee thereof) the relationship of employer and employee or of principal and agent Empire will not be liable in any lawsuit claim or demand for damages incurred or injuries that you may sustain resulting from care received either in a hospitalfacility or from a provider

42 wwwempirebluecom

Health Management Empirersquos Medical Management Program Managing your health includes getting the information you need to make informed decisions and making sure you get the maximum benefits the plan will pay To help you manage your health Empire provides the Empirersquos Medical Management Program a service that precertifies hospital admissions and certain treatments and procedures to help ensure that you receive the highest quality of care for the right length of time in the right setting and with the maximum available coverage Empirersquos Medical Management Program works with you and your provider to help confirm the medical necessity of services and help you make sound health care decisions The program helps ensure that you and your family members receive the highest quality of care at the right time in the most appropriate setting You can contact our Medical Management program by calling the Member Services telephone number located on the back of your identification card Empire may from time to time waive enhance modify or discontinue certain medical management processes (including utilization management case management and disease management) if in Empirersquos discretion such change is in furtherance of the provision of cost effective value based andor quality services In addition we may select certain qualifying Providers to participate in a program that exempts them from certain procedural or medical management processes that would otherwise apply We may also exempt your Claim from medical review if certain conditions apply Just because Empire exempts a process Provider or Claim from the standards which otherwise would apply it does not mean that Empire will do so in the future or will do so in the future for any other Provider Claim or Member Empire may stop or modify any such exemption with or without advance notice You may determine whether a Provider is participating in certain programs by checking your on-line Provider Directory or contacting customer service number on the back of your ID card

HOW EMPIRErsquoS MEDICAL MANAGEMENT PROGRAM HELPS YOU To help ensure that you receive the maximum coverage available to you Empirersquos Medical Management Program

x Reviews all planned and emergency hospital admissions x Reviews ongoing hospitalization x Performs case management x Coordinates discharge planning x Coordinates purchase and replacement of durable medical equipment prosthetics and orthotic requirements x Reviews inpatient and ambulatory surgery x Reviews high-risk maternity admissions x Reviews care in a hospice or skilled nursing or other facility

All other services will be subject to retrospective review by our Medical Management team to determine medical necessity The health care services on the following page must be precertified with Empirersquos Medical Management Program

wwwempirebluecom 43

CALL TO PRECERTIFY THE REQUIRED SERVICEShellip

FOR ALL HOSPITAL ADMISSIONS

x At least two weeks prior to any planned surgery or hospital admission x Within 48 hours of an emergency hospital admission or as soon as reasonably possible x Of newborns for illness or injury x Before you are admitted to a rehabilitation facility or a skilled nursing facility

MATERNITY CARE

x As soon as reasonably possible we request notification within the first three months of pregnancy when possible x Within 48 hours after the actual delivery date if stay is expected to extend beyond the minimum length of stay for

mother and newborn inpatient admission forty-eight (48) hours for a vaginal birth or ninety-six (96) hours for cesarean birth

BEFORE YOU RECEIVEUSE

x Inpatient Mental Health Care Substance Abuse Care and Alcohol Detoxification x Partial Hospital Programs Psychological Testing Intensive Outpatient Programs x Occupational physical speech and vision therapy x Outpatient Ambulatory Surgical Treatments (certain procedures) x Diagnostics x Outpatient Treatments x Durable medical equipment x Air ambulance

IF SERVICES ARE NOT PRECERTIFIED If you call to precertify services as needed you will receive maximum benefits Otherwise benefits may be reduced by 50 up to $2500 for each admission treatment or procedure This benefit reduction also applies to certain same-day surgery and professional services rendered during an inpatient admission If the admission or procedure is not medically necessary no benefits will be paid

1 Preauthorization Reviews

a Non-Urgent Preauthorization Reviews If We have all the information necessary to make a determination regarding a Preauthorization review We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of receipt of the request

If We need additional information We will request it within fifteen (15) calendar days You or Your Provider will then have 45 calendar days to submit the information If We receive the requested information within 45 days We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of Our receipt of the additional information If all necessary information is not received within 45 days We will make a determination within 15 calendar days of the end of the 45 day period allowed to submit the additional information

b Urgent Preauthorization Reviews With respect to urgent Preauthorization requests if We have all

information necessary to make a determination We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within 72 hours of receipt of the request If We need additional information We will request it within 24 hours You or Your Provider will then have 48 hours to submit the information We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within 48 hours of the earlier of Our receipt of the additional information or the end of the 48-hour period allowed to submit additional information

c Court Ordered Treatment With respect to requests for mental health andor substance use disorder

services that have not yet been provided if You (or Your designee) certify in a format prescribed by the Superintendent of Financial Services that You will be appearing or have appeared before a court of competent jurisdiction and may be subject to a court order requiring such services We will make a

44 wwwempirebluecom

determination and provide notice to You (or Your designee) and Your Provider by telephone within 72 hours of receipt of the request Written notification will be provided within three (3) business days of Our receipt of the request Where feasible the telephonic and written notification will also be provided to the court

2 Concurrent Reviews

1 Non-Urgent Concurrent Reviews Utilization Review decisions for services during the course of care (concurrent reviews) will be made and notice provided to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of receipt of all necessary information If We need additional information We will request it within fifteen (15) calendar days of the receipt of the request You or Your Provider will then have 45 calendar days to submit the additional information We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of Our receipt of the additional information or if We do not receive the information within 15 calendar days of the end of the 45-day period allowed to provide the additional information

2 Urgent Concurrent Reviews For concurrent reviews that involve an extension of urgent care if the

request for coverage is made at least 24 hours prior to the expiration of a previously approved treatment We will make a determination and provide notice to You (or Your designee) and Your Provider within 24 hours of receipt of the request If the request for coverage is not made at least 24 hours prior to the expiration of a previously approved treatment We will make a determination and provide written notice to You (or Your designee) and Your Provider within 72 hours of receipt of the request If We need additional information We will request it within 24 hours You or Your Provider will then have 48 hours to submit the information We will make a determination and provide written notice to You (or Your designee) and Your Provider within the earlier of one (1) business day or 48 hours of Our receipt of the information or if We do not receive the information within 48 hours of the end of the 48-hour period

3 Inpatient Substance Use Disorder Treatment Reviews If a request for inpatient substance use disorder treatment is submitted to Us at least 24 hours prior to discharge from an inpatient substance use disorder treatment admission We will make a determination within 24 hours of receipt of the request and We will provide coverage for the inpatient substance use disorder treatment while Our determination is pending

3 Retrospective Reviews If We have all information necessary to make a determination regarding a retrospective claim We will make a determination and notify You and Your Provider within 30 calendar days of the receipt of the request If We need additional information We will request it within 30 calendar days You or Your Provider will then have 45 calendar days to provide the information We will make a determination and provide notice to You and Your Provider in writing within 15 calendar days of the earlier of Our receipt of all or part of the requested information or the end of the 45-day period

Once We have all the information to make a decision Our failure to make a Utilization Review determination within the applicable time frames set forth above will be deemed an adverse determination subject to an internal Appeal

4 Retrospective Review of Preauthorized Services We may only reverse a preauthorized treatment service

or procedure on retrospective review when x The relevant medical information presented to Us upon retrospective review is materially different

from the information presented during the Preauthorization review x The relevant medical information presented to Us upon retrospective review existed at the time of the

Preauthorization but was withheld or not made available to Us x We were not aware of the existence of such information at the time of the Preauthorization review

and x Had We been aware of such information the treatment service or procedure being requested would

not have been authorized The determination is made using the same specific standards criteria or procedures as used during the Preauthorization review

5 Reconsideration If We did not attempt to consult with Your Provider who recommended the Covered

Service before making an adverse determination the Provider may request reconsideration by the same

wwwempirebluecom 45

clinical peer reviewer who made the adverse determination or a designated clinical peer reviewer if the original clinical peer reviewer is unavailable For Preauthorization and concurrent reviews the reconsideration will take place within one (1) business day of the request for reconsideration If the adverse determination is upheld a notice of adverse determination will be given to You and Your Provider and in writing

If Empirersquos Medical Management Program does not meet the above time frames the failure should be considered a denial You or your doctor may immediately appeal

IF A REQUEST IS DENIED All denials of benefits will be rendered by qualified medical personnel If a request for care or services is denied for lack of medical necessity or because the service has been determined to be experimental or investigational Empirersquos Medical Management Program will send a notice to you and your doctor with the reasons for the denial You will have the right to appeal See section in this booklet titled ldquoComplaints Appeals and Grievancesrdquo for more information

If Empirersquos Medical Management Program denies benefits for care or services without discussing the decision with your doctor your doctor is entitled to ask Medical Management to reconsider their decision A response will be provided by telephone and in writing within one business day of making the decision

46 wwwempirebluecom

New Medical Technology REQUESTING COVERAGE

Empire uses a committee composed of Empire Medical Directors who are doctors and participating network physicians to continuously evaluate new medical technology that has not yet been designated as a covered service If you want to request certification of a new medical technology before beginning treatment your provider must contact Empirersquos Medical Management Program The provider will be asked to do the following

x Provide full supporting documentation about the new medical technology x Explain how standard medical treatment has been ineffective or would be medically inappropriate x Send us scientific peer reviewed literature that supports the effectiveness of this particular technology The literature

must not be in the form of an abstract or individual case study Empirersquos staff will evaluate the proposal in light of your contract and Empirersquos current medical policy Empire will then review the proposal taking into account relevant medical literature including current peer review articles and reviews Empire may use outside consultants if necessary If the request is complicated Empire may refer your proposal to a multi-specialty team of physicians or to a national ombudsman program designed to review such proposals Empire will send all decisions to the member andor provider

Case Management IF YOU NEED ADDITIONAL SUPPORT FOR SERIOUS ILLNESS

The Medical Management Programrsquos Case Management staff can provide assistance and support when you or a member of your family faces a chronic or catastrophic illness or injury Empirersquos nurses can help you and your family

x Find appropriate cost-effective healthcare options x Reduce medical cost x Assure quality medical care

A Case Manager serves as a single source for patient provider and insurer ndash assuring that the treatment level of care and facility are appropriate for your needs For example Case Management can help with cases such as x Cancer x Stroke x AIDS

x Chronic illness x Hemophilia x Spinal cord and other traumatic injuries

Assistance from Case Management is evaluated and provided on a case-by-case basis In some situations Empirersquos Medical Management Program staff will initiate a review of a patients health status and the attending doctors plan of care They may determine that a level of benefits not necessarily provided by this plan is desirable appropriate and cost-effective If you would like Case Management assistance following an illness or surgery contact Empirersquos Medical Management Program at 1-800-982-8089

wwwempirebluecom 47

Preventive Services Preventive Care services include Outpatient services and Office Services Screenings and other services are covered as Preventive Care for adults and children with no current symptoms or prior history of a medical condition associated with that screening or service Members who have current symptoms or have been diagnosed with a medical condition are not considered to require Preventive Care for that condition but instead benefits will be considered under the Diagnostic Services benefit Preventive Care Services in this section shall meet requirements as determined by federal law Many Preventive Care Services are covered by this Benefit Program with no Deductible Copayments or Coinsurance from the Member when provided by a Network Provider These services fall under four broad categories as shown below A Items or services with an ldquoArdquo or ldquoBrdquo rating from the United States Preventive Services Task Force

Examples of these services are screenings for Breast cancer Cervical cancer Colorectal cancer High blood pressure Type 2 diabetes mellitus Cholesterol Child and adult obesity

B Immunizations pursuant to the Advisory Committee on Immunization Practices (ldquoACIPrdquo) recommendations including

the well-child care immunizations as listed below

x DPT (diphtheria pertussis and tetanus)

x Polio

x MMR (measles mumps and rubella)

x Varicella (chicken pox)

x Hepatitis B Hemophilus

x Tetanus-diphtheria

x Pneumococcal

x Meningococcal Tetramune

x Other immunizations as determined by the Superintendent of Insurance and the Commissioner of Health in New York State or the state where your child lives

C Preventive care and screenings that are provided for in the comprehensive guidelines supported by the Health Resources

and Services Administration (ldquoHRSArdquo) including

x Well-child care visits to a pediatrician nurse or licensed nurse practitioner including a physical examination medical history developmental assessment and guidance on normal childhood development and laboratory tests The tests may be performed in the office or a laboratory Covered services and the number of visits covered per year are based on the prevailing clinical standards of the American Academy of Pediatrics (AAP) and will be determined by your childrsquos age

x Bone Density Testing and Treatment Standards for determining appropriate coverage include the criteria of the

federal Medicare program and the criteria of the National Institutes of Health for the Detection of Osteoporosis Bone mineral density measurements or tests drugs and devices include those covered under Medicare and in accordance with the criteria of the National Institutes of Health including as consistent with such criteria dual energy X-ray absorptiometry Coverage shall be available as follows

For individuals who are Ages 52 through 65 - 1 baseline Age 65 and older - 1 every 2 years (if baseline before age 65 does not indicate osteoporosis)

48 wwwempirebluecom

Under Age 65 - 1 every 2 years (if baseline before age 65 indicates osteoporosis)

For individuals who meet the criteria of the above programs including one or more of the following Previously diagnosed with or having a family history of osteoporosis Symptoms or conditions indicative of the presence or significant risk of osteoporosis Prescribed drug regimen posing a significant risk of osteoporosis Lifestyle factors to such a degree posing a significant risk of osteoporosis Age gender andor other physiological characteristics that pose a significant risk of osteoporosis

D Womenrsquos Preventive Additional preventive care and screenings for women provided for in the guidelines supported by

the Health Resources and Services Administration including the following x Well-woman care visits to a gynecologistobstetrician x Women with no prior or family history of breast cancer get a baseline mammogram between ages 35-39 and for

ages 40 and over an annual mammogram Women who have a family history of breast cancer will be covered for a routine mammogram at any age and as often as their physician recommends one

x Womenrsquos contraceptives sterilization procedures and counseling This includes contraceptive devices such as

diaphragms intra uterine devices (IUDs) and implants as well as injectable contraceptives In addition coverage is available for generic and single-source brand name prescription drugs for oral contraceptives and patches dispensed from a pharmacy To obtain benefits prescription drugs must be approved by the federal Food and Drug Administration and must be obtained from a retail or mail order pharmacy that is a member of our Pharmacy Network Please see the Oral Contraceptive Prescription Drug Rider for more information

x Breastfeeding support supplies and counseling Covered in full when received from an In-Network Provider Benefits for breast pumps are limited to one pump per Calendar Year

x Screenings andor counseling where applicable for Gestational diabetes Human Papillomavirus (HPV) sexually transmitted infections (STIs) Human immune-deficiency virus (HIV) and interpersonal and domestic violence

Screening for Prostate Cancer

We Cover an annual standard diagnostic examination including but not limited to a digital rectal examination and a prostate specific antigen test for men age 50 and over who are asymptomatic and for men age 40 and over with a family history of prostate cancer or other prostate cancer risk factors We also Cover standard diagnostic testing including but not limited to a digital rectal examination and a prostate-specific antigen test at any age for men having a prior history of prostate cancer This benefit is not subject to Copayments Deductibles or Coinsurance when provided by a Participating Provider The preventive services referenced above shall be covered in full when received from In-Network Providers Cost sharing (eg Copayments Deductibles Coinsurance) may apply to services provided during the same visit as the preventive services set forth above For example if a service referenced above is provided during an office visit wherein that service is not the primary purpose of the visit the cost-sharing amount that would otherwise apply to the office visit will still apply A list of the preventive services covered under this paragraph is available on our website at wwwempirebluecom or will be mailed to you upon request You may request the list by calling the Customer Service number on your identification card

VOLUNTARY CLINICAL QUALITY PROGRAMS The purpose of these voluntary clinical quality programs is to promote good health and early detection of disease They are designed to encourage eligible Members to obtain certain covered Preventive Care or other recommended care covered under this Certificate that was not received within the recommended timeframe For instance a program may be designed to encourage You to bring Your child to his or her PCP for a well-child or well-baby care visit if You missed a recommended check-up or may encourage You to get certain screening tests such as a mammogram if You have not been tested within the recommended age range Or a program may encourage You to have a medical visit within a specific time period such as a postpartum checkup within a set number of days after delivery of a newborn or a home visit so you can provide a blood sample for a recommended laboratory test

a Description These voluntary clinical quality programs are designed to encourage You to get certain preventive

wwwempirebluecom 49

wellness or other recommended care when You need it based on recommended clinical guidelines These programs are not guaranteed and Your participation is optional We will give You the choice and if You choose to participate in any program for which You qualify and obtain the recommended care within the programrsquos timeframe You will receive an incentive The incentive will take the form of

i a gift card in the amount of $50 or retailer coupons such as for discounts on eye glasses

ii a home test kit at no cost to allow you to conveniently collect a specimen for certain covered laboratory tests at home and mail it to the laboratory for processing In this case You may need to pay any cost shares that normally apply to covered laboratory tests under your benefit plan but the home test kit will be free to You or

iii a home visit to allow you to provide a specimen for certain covered laboratory tests or for certain biometric screenings In this care You may need to pay any cost shares that normally apply to covered laboratory tests but the home visit will be free to You

If you have any questions about whether receipt of a gift card or retailer coupon results in taxable income to You we recommend that you consult Your tax advisor

b Eligibility You the Subscriber and the Subscriberrsquos covered Spouse and each covered Dependent can

participate in the Voluntary Clinical Quality Program(s) if the targeted service applies based on the recommended clinical guidelines the program promotes These programs will be offered to Members who have certain conditions who fall within certain age ranges or who are due to receive certain recommended preventive or other care based on a recommended timeframe For example

i Members age 50-75 years who have not undergone colorectal cancer screening as recommended by the American Cancer Society may be eligible to participate in a program designed to encourage these members to obtain a recommended preventive colorectal cancer screening such as a fecal occult blood screening test

ii Members age 50-74 years who have not had a mammography screening as

recommended by the United States Preventive Services Task Force may be eligible to participate in a program designed to encourage these members to obtain the screening through the offer of a gift card awarded upon receipt of documentation that the screening was completed

c Participation If You are eligible for a clinical quality program we offer we will contact You by phone or mail to

offer You the chance to participate You may also call us at the phone number on Your ID card if You have any questions regarding program participation We will explain to You the care You are recommended to receive and the time frame within which You need to receive it to be in eligible for the reward if applicable

d Rewards Rewards for participation in a clinical quality program and completion of the identified services within the specified timeframe include monetary rewards in the form of a gift card or retailer coupon such as for discounts on eye glasses so long as the recipient is encouraged to use the reward for a product or service that promotes good health In other cases You will receive a home test kit at no cost to make it more convenient for You to receive the recommended care

50 wwwempirebluecom

Wellness Programs A Purpose The purpose of Our wellness program(s) is to encourage You to take a more active role in

managing Your health and well-being Our wellness-related programs are designed to help You achieve Your best health These programs are not Covered services under Your Plan but are separate components which are not guaranteed under Your Plan and could be discontinued at any time Participation is voluntary and You can discontinue the program at any time

B Description We provide benefits in connection with the use of or participation in any of the following wellness and health promotion actions and activities 1 Health Assessment Completion A Health Assessment is an online health tool You will answer

questions about Your lifestyle current health and history You will have access to a personal report with health tips and available online programs

x Eligibility The Subscriber and the Subscriberrsquos covered Spouse or Domestic Partner age 18 and older can participate in the program

x Participation To access the Health Assessment register or log in to Our website at wwwempirebluecom If You havenrsquot set up a user name and password select Register Now to set them up Then click on the Health amp Wellness tab and select ldquoTake my HA nowrdquo to complete the assessment On Your first visit to the site Yoursquoll be asked to give Your email address and choose health topics of interest If You do not have access to a computer please call Us at the number on Your ID card and We will provide You with information regarding how to participate without internet access We will provide You with a paper Health Assessment that will allow You to participate without computer access

2 Future Moms Future Moms is a maternity management program which provides individualized support

to expectant moms to help them achieve healthier pregnancies and deliveries The program provides education and support for high-risk and non-high-risk expectant mothers

x Eligibility The Subscriber and the Subscriberrsquos covered Spouse or Domestic Partner age 18 and older can participate in the program

x Participation Expectant moms can sign up and enroll by calling Us toll free at 800-828-5891 One of Our registered nurses will help You get started

3 Behavioral Health Resource Our Behavioral Health Resource program provides individualized support

from care managers to members with behavioral health conditions such as depression and anxiety Care managers are licensed mental health professionals whose goals are to help you take control of your health care and improve your quality of life Members have access to

x Our telephonic behavioral health resource center available 24 hours a day 7 days a week for assessment referral education coaching and crisis resolution including depression care management eating disorder management and management of other complex behavioral health concerns

x The programrsquos online and mobile app wellness tools These tools offer customized ways to address topics such as stress management anxiety depression substance abuse and chronic pain The program employs personalized tools evidence-based resources and individually-tailored eLearning programs to help members learn and practice new ways to manage their mental well-being

x Eligibility The Subscriber and each covered Dependent are eligible for the program x Participation You may call Us toll free at the number on Your ID card A care manager

will help You get started In addition We may use claims history to identify and contact potential candidates by phone to discuss whether the program is right for them

wwwempirebluecom 51

Details and Definitions In this section wersquoll cover the details you need to know to make the plan work for you Use it as a reference to understand

x Who is eligible for coverage under your plan x How to file a claim and get your benefits paid

x Your rights to appeal a claim payment or Medical Management decision

x What we mean by certain healthcare terms Knowing the details can make a difference in how satisfied you are with your plan and how easy it is for you to use If you have additional questions please visit wwwempirebluecom or call Member Services at 1-855-519-9537

Eligibility The eligibility rules and administrative procedures for adding and removing dependents for your coverage are sent out in an annually distributed official issuance of the United Nations Please do not contact Empire regarding enrollment or eligibility questions

52 wwwempirebluecom

Claims IF YOU NEED TO FILE A CLAIM

Empire makes healthcare easy by paying providers directly when you stay in-network Therefore when you receive care from providers or facilities in the Empire or BlueCard PPO networks you generally do not have to file a claim However you will have to file a claim for reimbursement for covered services received out-of-network from a non-participating provider or if you have a medical emergency out of the Empire service area To obtain a claim form call customer service

TYPE OF CLAIM IN-NETWORK OUT-OF-NETWORK

HOSPITAL Provider files claim directly with Empire or local Blue CrossBlue Shield plan

Provider files claim with Empire or local Blue CrossBlue Shield plan

MEDICAL Provider files claim directly with Empire or local Blue CrossBlue Shield plan You file claim with Empire

AMBULANCE CHARGES Provider files claim directly with Empire or local Blue CrossBlue Shield plan You file claim with Empire

At some out-of-area and non-participating hospitals you may have to pay the hospitalrsquos bill If this happens include an original itemized hospital bill with your claim

Send completed forms to

Hospital Claims

Empire BlueCross BlueShield PO Box 1407 Church Street Station New York NY 10008-1407 Attention Institutional Claims Department

Medical Claims

Empire BlueCross BlueShield PO Box 1407 Church Street Station New York NY 10008-1407 Attention Medical Claims Department

Want more claim information Now you can check the status of a claim view and print Explanation of Benefits (EOB) correct certain claim information and more at any time of day or night just by visiting wwwempirebluecom

Assignment

You authorize Empire on behalf of the Employer to make payments directly to participating In-Network Providers for Covered Services Empire also reserves the right to make payments directly to you Except where Empire expressly indicates otherwise in the case of services provided by an out of network provider payments will always be made directly to you for services provided by the out of network provider Payments may also be made to and notice regarding the receipt andor adjudication of claims an Alternate Recipient or that personrsquos custodial parent or designated representative Any payments made by Empire will discharge the Employerrsquos obligation to pay for Covered Services You cannot assign your right to receive payment to anyone else except as required by a ldquoQualified Medical Child Support orderrdquo as defined by ERISA or any applicable state or Federal law Once a Provider performs a Covered Service Empire will not honor a request to withhold payment of the claims submitted The coverage and any benefits under the Plan are not assignable by any Member without the written consent of the Plan except as provided above

wwwempirebluecom 53

Tips for Filing a Claim x File claims within 18 months of date of service x Visit wwwempirebluecom to print out a claim form immediately or contact Member Services at 1-855-519-9537

to have one mailed to you x Complete all information requested on the form x Submit all claims in English or with an English translation x Attach original bills or receipts Photocopies will not be accepted x If Empire is the secondary payer submit the original or a copy of the primary payerrsquos Explanation of Benefits (EOB)

with your itemized bill x Keep a copy of your claim form and all attachments for your records

REMEMBER File claims within 24 months of the date of service to receive benefits

IF YOU HAVE MEDICAL COVERAGE UNDER TWO PLANS (COORDINATION OF BENEFITS ndash COB) Empire has a coordination of benefits (COB) feature that applies when you and members of your family are covered under more than one health plan The benefits provided by Empire will be coordinated with any benefits you are eligible to receive under the other plan Together the plans will pay up to the amount of covered expenses but not more than the amount of actual expenses When you are covered under two plans one plan has primary responsibility to pay benefits and the other has secondary responsibility The plan with primary responsibility pays benefits first

FRAUD AND ABUSIVE BILLING We have processes to review claims before and after payment to detect fraud and abusive billing In addition We may identify certain Providers to review for potential fraud waste abuse or other inappropriate activity if the claims data suggests there may be inappropriate billing practices If a Provider is selected for review under this program then as part of the review process We may use one or more clinical utilization management guidelines in the review of claims submitted by this Provider even if those guidelines are not used for all Providers delivering services to the Planrsquos Members

Members seeking services from Non-Participating Providers could be balance billed by the Non-Participating Provider for those services that are determined to be not payable as a result of a reasonable belief of fraud or other intentional misconduct or abusive billing

Which Plan Pays Benefits First Here is how Empire determines which plan has primary responsibility for paying benefits

x If the other health plan does not have a coordination of benefits feature that plan is primary x If you are covered as an employee under the Empire plan and as a dependent under the other plan your Empire plan

is primary x For a dependent child covered under both parentsrsquo plans the primary plan is

The plan of the parent whose birthday comes earlier in the calendar year (month and day) The plan that has covered the parent for a longer period of time if the parents have the same birthday The fatherrsquos plan if the other plan does not follow the ldquobirthday rulerdquo and uses gender to determine primary

responsibility If the parents are divorced or separated (and there is no court decree establishing financial responsibility for the

childrsquos healthcare expenses) the plan covering the parent with custody is primary If the parent with custody is remarried his or her plan pays first the step-parentrsquos plan pays second and the non-

custodial parentrsquos plan pays third If the parents are divorced or separated and there is a court decree specifying which parent has financial

responsibility for the childrsquos healthcare expenses that parentrsquos plan is primary once the plan knows about the decree

x If you are actively employed your plan is primary in relation to a plan for laid-off or retired employees x If none of these rules apply the plan that has covered the patient longest is primary

If Empire Is the Secondary Plan If the Empire plan is secondary then benefits will be reduced so the total benefits paid by both plans will not be greater than the allowable expenses Also Empire will not pay more than the amount Empire would normally pay if Empire were primary

Tips for Coordinating Benefits x To receive all the benefits available to you file your claim under each plan x File claims first with the primary plan then with the secondary plan

54 wwwempirebluecom

x Include the original or a copy of the Explanation of Benefits (EOB) from the primary plan when you submit your bill to the secondary plan Remember to keep a copy for your records

If You Receive An Overpayment Of Benefits If you receive benefits that either should not have been paid or are more than should have been paid you must return any overpayment to Empire within 60 days of receiving it Overpayments include

x Payment for a service not covered by the plan x Payment for a person not covered by the plan x Payment that exceeds the amount due under your plan x Duplicate payments for the same services

Subrogation and Right of Reimbursement

These provisions apply when Plan benefits are paid as a result of injuries or illness you sustained and you have a right to a Recovery or have received a Recovery

Subrogation

The Administrator on behalf of the Employer has the right to recover Plan payments made on your behalf from any party responsible for compensating you for your injuries The following apply

x The Administrator on behalf of the Employer has the first priority for the full amount of benefits they have paid from any Recovery regardless of whether you are fully compensated and regardless of whether the payments you receive make you whole for your losses and injuries

x You and your legal representative must do whatever is necessary to enable the Administrator on behalf of the Employer to exercise their rights and do nothing to prejudice them

x The Administrator on behalf of the Employer has the right to take whatever legal action they see fit against any party or entity to recover the benefits paid under the Plan

x To the extent that the total assets from which a Recovery is available are insufficient to satisfy in full the Administrators subrogation claim and any claim still held by you The Administratorrsquos subrogation claim shall be first satisfied before any part of a Recovery is applied to your claim your attorney fees other expenses or costs

The Administrator on behalf of the Employer is not responsible for any attorney fees other expenses or costs without its prior written consent The Administrator on behalf of the Employer further agrees that the ldquocommon fundrdquo doctrine does not apply to any funds recovered by any attorney you hire regardless of whether funds recovered are used to repay benefits paid by the Administrator on behalf of the Employer

Reimbursement

If you obtain a Recovery and the Administrator on behalf of the Employer has not been repaid for the benefits the Administrator on behalf of the Employer paid on your behalf the Administrator on behalf of the Employer shall have a right to be repaid from the Recovery in the amount of the benefits paid on your behalf and the following apply

x You must reimburse the Administrator on behalf of the Employer to the extent of Plan benefits the Administrator on behalf of the Employer paid on your behalf from any Recovery

x Notwithstanding any allocation made in a settlement agreement or court order the Administrator on behalf of the Employer shall have a right of Recovery in first priority against any Recovery

x You and your legal representative must hold in trust for the Administrator on behalf of the Employer the proceeds of the gross Recovery (ie the total amount of your Recovery before attorney fees other expenses or costs) to be paid to the Administrator on behalf of the Employer immediately upon your receipt of the Recovery You must reimburse the Employer in first priority and without any set-off or reduction for attorney fees other expenses or costs The ldquocommon fundrdquo doctrine does not apply to any funds recovered by any attorney You hire regardless of whether funds recovered are used to repay benefits paid by the Administrator on behalf of the Employer

x If You fail to repay the Administrator on behalf of the Employer the Administrator on behalf of the Employer shall be entitled to deduct any of the unsatisfied portion of the amount of benefits the Administrator on behalf of the Employer has paid or the amount of your Recovery whichever is less from any future benefit under the Plan if The amount the Administrator on behalf of the Employer paid on your behalf is not repaid or otherwise

recovered by the Administrator on behalf of the Employer or You fail to cooperate

x In the event that You fail to disclose to the Administrator andor the Employer the amount of your settlement the Administrator on behalf of the Employer shall be entitled to deduct the amount of their lien from any future benefit under the Plan

wwwempirebluecom 55

x The Administrator on behalf of the Employer shall also be entitled to recover any of the unsatisfied portions of the amount they have paid or the amount of your settlement whichever is less directly from the Providers to whom the Administrator on behalf of the Employer has made payments In such a circumstance it may then be your obligation to pay the Provider the full billed amount and the Administrator on behalf of the Employer would not have any obligation to pay the Provider

The Administrator on behalf of the Employer is entitled to reimbursement from any Recovery in first priority even if the Recovery does not fully satisfy the judgment settlement or underlying claim for damages or fully compensate or make you whole

Your Duties

x You must notify the Administrator on behalf of the Employer promptly of how when and where an accident or incident resulting in personal injury or illness to you occurred and all information regarding the parties involved

x You must cooperate with the Administrator on behalf of the Employer in the investigation settlement and protection of the Employers rights of the Administrator on behalf of the Employer

x You must not do anything to prejudice the rights of the Administrator on behalf of the Employer x You must send the Administrator on behalf of the Employer copies of all police reports notices or other papers

received in connection with the accident or incident resulting in personal injury or illness to you x You must promptly notify the Administrator on behalf of the Employer if you retain an attorney or if a lawsuit is

filed on your behalf

Health Care Fraud Illegal activity adds to everyonersquos cost for healthcare Thatrsquos why Empire welcomes your help in fighting fraud If you know of any person receiving Empire benefits that they are not entitled to call us We will keep your identity confidential Want to see some recent examples of Empirersquos fraud prevention efforts Visit wwwempirebluecom

REMEMBER FRAUD HOTLINE 1-800-ICFRAUD (423-7283) During normal business hours

If You Have Questions About a Benefit Payment Empire reviews each claim for appropriate services and correct information before it is paid Once a claim is processed an Explanation of Benefits (EOB) will be sent directly to you if you have any responsibility on the claim other than your co-payment amount or if an adjustment is performed on your claim If Empire reduces or denies a claim payment you will receive a written notification or an Explanation of Benefits (EOB) citing the reasons your claim was reduced or denied The notification will give you

x The specific reason(s) for the denial x References to the pertinent plan provisions on which the denial is based x A description of any additional material or information necessary for you to establish the claim and an explanation of

why this material or information is necessary x An explanation of claims review procedures

If you have any questions about your claim your Benefits Administrator may be able to help you answer them You may also contact Empire Member Services at 1-855-519-9537 or in writing for more information When you call be sure to have your Empire ID card number handy along with any information about your claim Send written inquiries to

Empire BlueCross BlueShield PPO Member Services PO Box 1407 Church Street Station New York NY 10008-1407

56 wwwempirebluecom

Reimbursement For Covered Services Maximum Allowed Amount This section describes how We determine the amount of reimbursement for Covered Services Reimbursement for services rendered by In-Network and Out-of-Network Providers is based on the Maximum Allowed Amount for the Covered Service that you receive Please see the Blue Cross and Blue Shield Association BlueCard Program section for additional information regarding services received outside of Empirersquos service area

The Maximum Allowed Amount is the maximum amount of reimbursement Empire will pay for services and supplies

x that meet our definition of Covered Services to the extent such services and supplies are covered under Your

Plan and are not excluded x that are Medically Necessary and x that are provided in accordance with all applicable preauthorization Medical Management Programs or other

requirements set forth in Your Plan You will be required to pay a portion of the Maximum Allowed Amount to the extent you have not met your Deductible or have a Copayment or Coinsurance In addition when you receive Covered Services from an Out-of-Network Provider you may be responsible for paying any difference between the Maximum Allowed Amount and the Providerrsquos actual charges This amount can be significant

When you receive Covered Services from a Provider We will to the extent applicable apply claim processing rules to the claim submitted for those Covered Services These rules evaluate the claim information and determine among other things the appropriateness of the procedure and diagnosis codes included in the claim Applying these rules may affect our determination of the Maximum Allowed Amount Our application of these rules does not mean that the Covered Services you received were not Medically Necessary It means We have determined that the claim submitted was inconsistent with procedure coding rules andor our reimbursement policies For example your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed When this occurs the Maximum Allowed Amount will be based on the single procedure code rather than a separate Maximum Allowed Amount for each billed code Likewise when multiple procedures are performed on the same day by the same Provider or other healthcare professional We may reduce the Maximum Allowed Amounts for those secondary and subsequent procedures because reimbursement at 100 of the Maximum Allowed Amount for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive

PROVIDER NETWORK STATUS The Maximum Allowed Amount may vary depending upon whether the Provider is an In-Network Provider or an Out-of-Network Provider

For Covered Services performed by an In-Network Provider the Maximum Allowed Amount is the rate the Provider has agreed with Empire to accept as reimbursement for the Covered Services Because In-Network Providers have agreed to accept the Maximum Allowed Amount as payment in full for that service they should not send you a bill or collect for amounts above the Maximum Allowed Amount However you may receive a bill or be asked to pay all or a portion of the Maximum Allowed Amount to the extent that you have not met your Deductible or have a Copayment or Coinsurance Please call Customer Service for help in finding an In-Network Provider or visit wwwempirebluecom

Providers who have not signed any contract with Us and are not in any of our networks are Out-of-Network Providers subject to Blue Cross and Blue Shield Association rules governing claims filed by certain ancillary Providers

For Covered Services that you receive from an Out-of-Network Provider the Maximum Allowed Amount will be based on our Out-of-Network Provider fee schedulerate or the Out-of-Network Providerrsquos charge this amount is currently 275 of Medicarersquos Fee Schedule whichever is less (except Certified Social Worker 225 and Physical Therapy 200) Our Out-of-Network Provider fee schedulerate may be accessed by calling the Customer Service number on the back of your identification card The Maximum Allowed Amount on our Out-of-Network Provider fee schedulerate has been developed by reference to one or more of several sources including the following

wwwempirebluecom 57

1 Amounts based on our In-Network Provider fee schedulerate 2 Amounts based on the level andor method of reimbursement used by the Centers for Medicare and Medicaid

Services unadjusted for geographic locality for the same services or supplies Such reimbursement amounts will be updated no less than annually

3 Amounts based on charge cost reimbursement or utilization data 4 Amounts based on information provided by a third party vendor which may reflect one or more of the

following factors i) the complexity or severity of treatment ii) level of skill and experience required for the treatment or iii) comparable Providersrsquo fees and costs to deliver care or

5 An amount negotiated by the Claims Administrator or a third party vendor which has been agreed to by the Provider This may include rates for services coordinated through case management

The amount We pay a Non-Participating Provider for Emergency Services will be the greater of 1) the amount We have negotiated with Participating Providers for the Emergency Service (and if more than one amount is negotiated the median of the amounts) 2) 100 of the Allowed Amount for services provided by a Non-Participating Provider (ie the amount We would pay in the absence of any Cost-Sharing that would otherwise apply for services of Non-Participating Providers) or 3) the amount that would be paid under Medicare The amounts described above exclude any Copayment or Coinsurance that applies to Emergency Services provided by a Participating Provider For Covered Services rendered outside Empirersquos Service Area by Out-of-Network Providers claims may be priced using the local Blue Cross Blue Shield planrsquos non-participating provider fee schedule rate or the pricing arrangements required by applicable state or federal law In certain situations the Maximum Allowed Amount for out of area claims may be based on billed charges the pricing we would use if the healthcare services had been obtained within the Empire Service Area or a special negotiated price

Providers who are not contracted for this Plan but contracted for other Plans with Us are also considered Out-of-Network The Maximum Allowed Amount reimbursement for services from these Providers will be based on Our Out-of Network Provider fee schedulerate as described above unless the contract between Us and that Provider specifies a different amount

Unlike In-Network Providers Out-of-Network Providers may send you a bill and collect for the amount of the Providerrsquos charge that exceeds our Maximum Allowed Amount You are responsible for paying the difference between the Maximum Allowed Amount and the amount the Provider charges This amount can be significant Choosing an In-Network Provider will likely result in lower out of pocket costs to you Please call Customer Service for help in finding In-Network Providers or visit our website at wwwempirebluecom

Customer Service is also available to assist you in determining the Maximum Allowed Amount for a particular service from an Out-of-Network Provider In order for Us to assist you you will need to obtain from your Provider the specific procedure code(s) and diagnosis code(s) for the services the Provider will render You will also need to know the Providerrsquos charges to calculate your out of pocket responsibility Although Customer Service can assist you with this pre-service information the final Maximum Allowed Amount for your claim will be based on the actual claim submitted

MEMBER COST SHARE For certain Covered Services and depending on Your Plan you may be required to pay a part of the Maximum Allowed Amount as your cost share amount (for example Deductible Copayment andor Coinsurance)

Your cost share amount and out-of-pocket limit may vary depending on whether you received services from an In-Network or an Out-of-Network Provider Specifically you may be required to pay higher cost sharing amounts or may have limits on your benefits when using Out-of-Network Providers Please see the terms of this Benefit Booklet and Benefits At A Glance chart for your cost share amounts and limitations or call Customer Service to learn how Your Planrsquos benefits or cost share amounts may vary by the type of Provider you use

Empire will not provide any reimbursement for non-Covered Services You may be responsible for the total amount billed by your Provider for non-Covered Services regardless of whether such services are performed by an In-Network Provider or an Out-of-Network Provider Both services specifically excluded by the terms of Your Plan and those received after benefits have been exhausted are non-Covered Services Benefits may be exhausted by exceeding for example your lifetime maximum benefit caps or dayvisit limits Note that no Out-of-Network coverage is available for benefits that are listed as In-Network only in Your Plan

In some instances you may only be asked to pay the lower In-Network cost sharing amount when you use an Out-of-Network Provider For example if you go to an In-Network Hospital or Facility and receive Covered Services from an Out-of-Network

58 wwwempirebluecom

Provider such as a radiologist anesthesiologist or pathologist who is employed by or contracted with an In-Network Hospital or Facility you will pay the In-Network cost share amounts for those Covered Services However you also may be liable for the difference between the Maximum Allowed Amount and the Out-of-Network Providerrsquos charge

The following are examples for illustrative purposes only Please see Your Benefits At A Glance for Your applicable amounts

Example Your Plan has Coinsurance of 20 for In-Network services and 30 Out-of-Network after the In- or Out-of-Network Deductible has been met You undergo a surgical procedure in an In-Network Hospital The Hospital has contracted with an Out-of-Network anesthesiologist to perform the anesthesiology services for the surgery You have no control over the anesthesiologist used

The Out-of-Network anesthesiologistrsquos charge for the service is $1200 The Maximum Allowed Amount for the anesthesiology service is $950 your Coinsurance responsibility is 20 of $950 or $190 and the remaining allowance from Us is 80 of $950 or $760 You may receive a bill from the anesthesiologist for the difference between $1200 and $950 Provided the Deductible has been met your total out of pocket responsibility would be $190 (20 Coinsurance responsibility) plus an additional $250 for a total of $440 You choose an In-Network surgeon The charge is $2500 The Maximum Allowed Amount for the surgery is $1500 your Coinsurance when an In-Network surgeon is used is 20 of $1500 or $300 We allow 80 of $1500 or $1200 The In-Network surgeon accepts the total of $1500 as reimbursement for the surgery regardless of the charges Your total out of pocket responsibility would be $300 You choose an Out-of-Network surgeon The Out-of-Network surgeonrsquos charge for the service is $2500 The Maximum Allowed Amount for the surgery service is $1500 your Coinsurance for the Out-of-Network surgeon is 30 of $1500 or $450 after the Out-of-Network Deductible has been met We allow the remaining 70 of $1500 or $1050 In addition the Out-of-Network surgeon could bill you the difference between $2500 and $1500 so your total out of pocket charge would be $450 plus an additional $1000 for a total of $1450

AUTHORIZED SERVICES In some circumstances such as where there is no In-Network Provider available for the Covered Service We may authorize the In-Network cost share amounts (Deductible Copayment andor Coinsurance) to apply to a claim for a Covered Service you receive from an Out-of-Network Provider In such circumstance you must contact Us in advance of obtaining the Covered Service We will authorize the In-Network cost share amounts to apply to a claim for Covered Services if you receive Emergency services from an Out-of-Network Provider consistent with applicable state and federal regulations on Emergency Services If We authorize an Out-of-Network Covered Service so that you are responsible for the In-Network cost share amounts you may still be liable for the difference between the Maximum Allowed Amount and the Out-of-Network Providerrsquos charge Please contact Customer Service for information or to request authorization

The following are examples for illustrative purposes only Please see Your Benefits At A Glance chart for Your applicable amounts

Example You require the services of a specialist but there is no In-Network Provider for that specialty in your state of residence You contact Us in advance of receiving any Covered Services and We authorize you to go to an available Out-of-Network Provider for that Covered Service and We agree that the In-Network cost share will apply

Your Plan has a 30 Coinsurance for Out-of-Network Providers and a $25 Copayment for In-Network Providers for the Covered Service The Out-of-Network Providerrsquos charge for this service is $500 The Maximum Allowed Amount is $200

Because We have authorized the In-Network cost share amount to apply in this situation you will be responsible for the In-Network Copayment of $25 and Empire will be responsible for the remaining $175 of the $200 Maximum Allowed Amount

Because the Out-of-Network Providerrsquos charge for this service is $500 you may receive a bill from the Out-of-Network Provider for the difference between the $500 charge and the Maximum Allowed Amount of $200 Combined with your In-Network Copayment of $25 your total out of pocket expense would be $325

wwwempirebluecom 59

Complaints Appeals and Grievances Grievance Procedures A Grievances Our Grievance procedure applies to any issue not relating to a Medical Necessity or

experimental or investigational determination by Us For example it applies to contractual benefit denials or issues or concerns You have regarding Our administrative policies or access to Providers

B Filing a Grievance You can contact Us by phone at the number on Your ID card in person or in writing

to file a Grievance You may submit an oral Grievance in connection with a denial of a Referral or a covered benefit determination We may require that You sign a written acknowledgement of Your oral Grievance prepared by Us You or Your designee has up to 180 calendar days from when You received the decision You are asking Us to review to file the Grievance

When We receive Your Grievance We will mail an acknowledgment letter within 15 business days The acknowledgment letter will include the name address and telephone number of the person handling Your Grievance and indicate what additional information if any must be provided

We keep all requests and discussions confidential and We will take no discriminatory action because of Your issue We have a process for both standard and expedited Grievances depending on the nature of Your inquiry

C Grievance Determination Qualified personnel will review Your Grievance or if it is a clinical matter a

licensed certified or registered Health Care Professional will look into it We will decide the Grievance and notify You within the following timeframes

ExpeditedUrgent Grievances By phone within the earlier of 48 hours of receipt of all

necessary information or 72 hours of receipt of Your Grievance Written notice will be provided within 72 hours of receipt of Your Grievance

Pre-Service Grievances (A request for a service or treatment that has not yet been provided)

In writing within 15 calendar days of receipt of Your Grievance

Post-Service Grievances (A claim for a service or treatment that has already been provided)

In writing within 30 calendar days of receipt of Your Grievance

All Other Grievances (That are not in relation to a claim or request for a service or treatment)

In writing within 45 calendar days of receipt of all necessary information but no more than 60 calendar days of receipt of Your Grievance

D Grievance Appeals If You are not satisfied with the resolution of Your Grievance You or Your

designee may file an Appeal by phone at the number on Your ID card in person or in writing You have up to 60 business days from receipt of the Grievance determination to file an Appeal

When We receive Your Appeal We will mail an acknowledgment letter within 15 business days The acknowledgement letter will include the name address and telephone number of the person handling Your Appeal and indicate what additional information if any must be provided

One or more qualified personnel at a higher level than the personnel that rendered the Grievance determination will review it or if it is a clinical matter a clinical peer reviewer will look into it We will decide the Appeal and notify You in writing within the following timeframes

ExpeditedUrgent Grievances The earlier of two (2) business days of receipt of all

60 wwwempirebluecom

necessary information or 72 hours of receipt of Your Appeal

Pre-Service Grievances (A request for a service or treatment that has not yet been provided)

15 calendar days of receipt of Your Appeal

Post-Service Grievances (A claim for a service or treatment that has already been provided)

30 calendar days of receipt of Your Appeal

All Other Grievances (That are not in relation to a claim or request for a service or treatment)

30 business days of receipt of all necessary information to make a determination

Utilization Review 1 Utilization Review We review health services to determine whether the services are or were Medically

Necessary or experimental or investigational (Medically Necessary) This process is called Utilization Review Utilization Review includes all review activities whether they take place prior to the service being performed (Preauthorization) when the service is being performed (concurrent) or after the service is performed (retrospective) If You have any questions about the Utilization Review process please call the number on Your ID card The toll-free telephone number is available at least 40 hours a week with an after-hours answering machine

All determinations that services are not Medically Necessary will be made by 1) licensed Physicians or 2) licensed certified registered or credentialed Health Care Professionals who are in the same profession and same or similar specialty as the Provider who typically manages Your medical condition or disease or provides the health care service under review or 3) with respect to mental health or substance use disorder treatment licensed Physicians or licensed certified registered or credentialed Health Care Professionals who specialize in behavioral health and have experience in the delivery of mental health or substance use disorder courses of treatment We do not compensate or provide financial incentives to Our employees or reviewers for determining that services are not Medically Necessary We have developed guidelines and protocols to assist Us in this process For substance use disorder treatment We will use evidence-based and peer reviewed clinical review tools designated by OASAS that are appropriate to the age of the patient Specific guidelines and protocols are available for Your review upon request For more information call the number on Your ID card or visit Our website at wwwempirebluecom

2 Utilization Review Internal Appeals You Your designee and in retrospective review cases Your

Provider may request an internal Appeal of an adverse determination either by phone in person or in writing

You have up to 180 calendar days after You receive notice of the adverse determination to file an Appeal We will acknowledge Your request for an internal Appeal within 15 calendar days of receipt This acknowledgment will include the name address and phone number of the person handling Your Appeal and if necessary inform You of any additional information needed before a decision can be made The Appeal will be decided by a clinical peer reviewer who is not subordinate to the clinical peer reviewer who made the initial adverse determination and who is 1) a Physician or 2) a Health Care Professional in the same or similar specialty as the Provider who typically manages the disease or condition at issue

1 Out-of-Network Service Denial You also have the right to Appeal the denial of a Preauthorization

request for an out-of-network health service when We determine that the out-of-network health service is not materially different from an available in-network health service A denial of an out-of-network health service is a service provided by a Non-Participating Provider but only when the service is not available from a Participating Provider For a Utilization Review Appeal of denial of an out-of-network health service You or Your designee must submit

x A written statement from Your attending Physician who must be a licensed board-certified or board-eligible Physician qualified to practice in the specialty area of practice appropriate to treat Your condition that the requested out-of-network health service is materially different from the alternate health service available from a Participating Provider that We approved to treat Your condition and

wwwempirebluecom 61

x Two (2) documents from the available medical and scientific evidence that the out-of-network service 1) is likely to be more clinically beneficial to You than the alternate in-network service and 2) that the adverse risk of the out-of-network service would likely not be substantially increased over the in-network health service

2 Out-of-Network Authorization Denial You also have the right to Appeal the denial of a request for an

authorization to a Non-Participating Provider when We determine that We have a Participating Provider with the appropriate training and experience to meet Your particular health care needs who is able to provide the requested health care service For a Utilization Review Appeal of an out-of-network authorization denial You or Your designee must submit a written statement from Your attending Physician who must be a licensed board-certified or board-eligible Physician qualified to practice in the specialty area of practice appropriate to treat Your condition

x That the Participating Provider recommended by Us does not have the appropriate training and experience to meet Your particular health care needs for the health care service and

x Recommending a Non-Participating Provider with the appropriate training and experience to meet Your particular health care needs who is able to provide the requested health care service

3 First Level Appeal

1 Preauthorization Appeal If Your Appeal relates to a Preauthorization request We will decide the Appeal

within 15 calendar days of receipt of the Appeal request Written notice of the determination will be provided to You (or Your designee) and where appropriate Your Provider within two (2) business days after the determination is made but no later than 15 calendar days after receipt of the Appeal request

2 Retrospective Appeal If Your Appeal relates to a retrospective claim We will decide the Appeal within

30 calendar days of receipt of the Appeal request Written notice of the determination will be provided to You (or Your designee) and where appropriate Your Provider within two (2) business days after the determination is made but no later than 30 calendar days after receipt of the Appeal request

3 Expedited Appeal An Appeal of a review of continued or extended health care services additional

services rendered in the course of continued treatment home health care services following discharge from an inpatient Hospital admission services in which a Provider requests an immediate review mental health andor substance use disorder services that may be subject to a court order or any other urgent matter will be handled on an expedited basis An expedited Appeal is not available for retrospective reviews For an expedited Appeal Your Provider will have reasonable access to the clinical peer reviewer assigned to the Appeal within one (1) business day of receipt of the request for an Appeal Your Provider and a clinical peer reviewer may exchange information by telephone or fax An expedited Appeal will be determined within the earlier of 72 hours of receipt of the Appeal or two (2) business days of receipt of the information necessary to conduct the Appeal

If You are not satisfied with the resolution of Your expedited Appeal You may file a standard internal Appeal or an external review Our failure to render a determination of Your Appeal within 30 calendar days of receipt of the necessary information for a standard Appeal or within two (2) business days of receipt of the necessary information for an expedited Appeal will be deemed a reversal of the initial adverse determination

Substance Use Appeal If We deny a request for inpatient substance use disorder treatment that was submitted at least 24 hours prior to discharge from an inpatient admission and You or Your Provider file an expedited internal Appeal of Our adverse determination We will decide the Appeal within 24 hours of receipt of the Appeal request If You or Your Provider file the expedited internal Appeal and an expedited external review within 24 hours of receipt of Our adverse determination We will also provide coverage for the inpatient substance use disorder treatment while a determination on the internal Appeal and external review is pending

4 Second Level Appeal If You disagree with the first level Appeal determination You or Your designee can file a second level Appeal You or Your designee can also file an external review The four (4) month timeframe for filing an external review begins on receipt of the final adverse determination on the first level of Appeal By choosing to file a second level Appeal the time may expire for You to file for external review

62 wwwempirebluecom

A second level Appeal must be filed within 60 days of receipt of the final adverse determination on the first level Appeal We will acknowledge Your request for an internal Appeal within 15 calendar days of receipt This acknowledgment will include the name address and phone number of the person handling Your Appeal and inform You if necessary of any additional information needed before a decision can be made

1 Preauthorization Appeal If Your Appeal relates to a Preauthorization request We will decide the

Appeal within 15 calendar days of receipt of the Appeal request Written notice of the determination will be provided to You (or Your designee) and where appropriate Your Provider within two (2) business days after the determination is made but no later than 15 calendar days after receipt of the Appeal request

2 Retrospective Appeal If Your Appeal relates to a retrospective claim We will decide the Appeal within

30 calendar days of receipt of the Appeal request Written notice of the determination will be provided to You (or Your designee) and where appropriate Your Provider within two (2) business days after the determination is made but no later than 30 calendar days after receipt of the Appeal request

3 Expedited Appeal If Your Appeal relates to an urgent matter We will decide the Appeal and provide written notice of the determination to You (or Your designee) and where appropriate Your Provider within 72 hours of receipt of the Appeal request ]

External Review

A If the outcome of the mandatory first level appeal is adverse to you you may be eligible for an independent

External Review pursuant to federal law You must submit your request for External Review to the Claims Administrator within four (4) months of the notice of your final internal adverse determination A request for an External Review must be in writing unless the Claims Administrator determines that it is not reasonable to require a written statement You do not have to re-send the information that you submitted for internal appeal However you are encouraged to submit any additional information that you think is important for review

B For pre-service claims involving urgentconcurrent care you may proceed with an Expedited External Review without filing an internal appeal or while simultaneously pursuing an expedited appeal through our internal appeal process You or your authorized representative may request it orally or in writing All necessary information including the Claims Administratorrsquos decision can be sent between the Claims Administrator and you by telephone facsimile or other similar method To proceed with an Expedited External Review you or your authorized representative must contact the Claims Administrator at the number shown on your identification card and provide at least the following information

x the identity of the claimant x the date (s) of the medical service x the specific medical condition or symptom x the providerrsquos name x the service or supply for which approval of benefits was sought and x any reasons why the appeal should be processed on a more expedited basis

C All other requests for External Review should be submitted in writing unless the Claims Administrator

determines that it is not reasonable to require a written statement Such requests should be submitted by you or your authorized representative to

Empire Appeal and Grievance Department PO Box 1407

Church Street Station New York NY 10008-1407

This is not an additional step that you must take in order to fulfill your appeal procedure obligations described above Your decision to seek External Review will not affect your rights to any other benefits under this health care plan There is no charge for you to initiate an independent External Review The External Review decision is final and binding on all parties except for any relief available through applicable state laws or ERISA

wwwempirebluecom 63

Ending and Continuing Coverage WHEN COVERAGE ENDS

Your Empire plan coverage may terminate for any of the following reasons x Your group terminates the contract x Your employer no longer meets our underwriting standards x Your employer fails to pay premiums x You fail to pay premiums (if required) x The covered employee dies x You or your covered dependents no longer meet your employerrsquos or the contractrsquos eligibility requirements x You or your covered dependents have made a false statement on an application for coverage or on a health insurance

claim form or you or your group have otherwise engaged in fraud x Empire discontinues this class of coverage

CONTINUING COVERAGE UNDER NEW YORK STATE LAW If you are not entitled to continuation of coverage under COBRA (for example your employer has fewer than 20 employees) you may be entitled to continue coverage under New York State Law These laws vary from those under COBRA but generally also require continued coverage for up to 18 29 or 36 months Call or write to your employer or Empire to find out if you are entitled to continuation of coverage under the New York State Insurance Law

THE VETERANS BENEFITS IMPROVEMENT ACT OF 2004 The Veterans Benefits Improvement Act of 2004 which amends the 1994 Uniformed Services Employment and Reemployment Rights Act (USERRA) extends the period for continuation of health care coverage as follows

If a covered persons health plan coverage would terminate because of an absence due to military service the person may elect to continue the health plan coverage for up to 24 months after the absence begins or for the period of service Similar to COBRA the person cannot be required to pay more than 102 percent (except where State requirements provide for a lesser amount) of the full premium for the coverage If military service was for 30 or fewer days the person cannot be required to pay more than the normal employee share of any premium

ENDING AND CONTINUING COVERAGE Your EmployerPlan Sponsor reserves the right to amend or terminate its group health plan coverage provided to you at any time without prior notice or approval The decision to end or amend the health plan coverage may be due to changes in federal or state laws governing welfare benefits the requirements of the Internal Revenue Code or ERISA or any other reason

Any amendment or termination may apply to all or any portion of the group health plan coverage and to all or to only a portion of the participants and beneficiaries

Certificates of Creditable Coverage After Termination Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) a certificate of coverage must be issued to a Member and his or her covered Dependents who terminate from this Benefit Program The information included on the Certificate of Creditable Coverage will include the names of any Members terminating the date coverage under this Benefit Program ended and the type of coverage provided under this Benefit Program This Certificate of Creditable Coverage will provide a subsequent insurer or group Plan with information regarding previous coverage to assist it in determining any Pre-Existing Condition exclusion period or Affiliation Period This Certificate of Creditable Coverage should be presented by the Member to his or her next Employer Group andor when applying for subsequent group health insurance A Certificate of Creditable Coverage will be issued to terminating Members within a reasonable amount of time after Empire has terminated membership In addition a terminated Member may request an additional copy of the Certificate of Creditable Coverage by contacting Member Services

64 wwwempirebluecom

ACCESS TO INFORMATION

In addition to calling Member Services for claim and benefit information you can contact them for x The names business addresses and official positions of Empirersquos Board of Directors officers controlling persons

owners and partners x Empirersquos most recently published annual financial statement x A consumer report of grievances filed with the Insurance Superintendent x Procedures that protect confidentiality of medical records and information x A copy of Empirersquos Drug Formulary x A directory of participating providers x A description of our quality assurance program x A notice of specific individual provider affiliations with participating hospitals x Upon written request specific written clinical criteria for determining if a procedure or test is medically necessary

For Members Who Donrsquot Speak English Empire will help members who speak languages other than English ask questions and file grievances in their first language When you call Member Services the operator will link you to an interpreter in your preferred language who can facilitate the discussion 247 NurseLine is also equipped to provide assistance in most languages

wwwempirebluecom 65

Your Rights and Responsibilities

We are committed to

x Recognizing and respecting you as a member x Encouraging your open discussions with your health care professionals and providers x Providing information to help you become an informed health care consumer x Providing access to health benefits and our network providers x Sharing our expectations of you as a member

You have the right to

x Participate with your health care professionals and providers in making decisions about your health care x Receive the benefits for which you have coverage x Be treated with respect and dignity x Privacy of your personal health information consistent with state and federal laws and our policies x Receive information about our organization and services our network of health care professionals and providers

and your rights and responsibilities x Candidly discuss with your physicians and providers appropriate or medically necessary care for your condition

regardless of cost or benefit coverage x Make recommendations regarding the organizations members rights and responsibilities policies x Voice complaints or appeals about our organization any benefit or coverage decisions we (or our designated

administrators) make your coverage or care provided x Refuse treatment for any condition illness or disease without jeopardizing future treatment and be informed by

your physician(s) of the medical consequences x Participate in matters of the organizationrsquos policy and operations x The member has the right to obtain complete and current information concerning a diagnosis treatment and

prognosis from a physician or other provider in terms that the member can be reasonably expected to understand When it is not advisable to give such information to the member the information will be made available to an appropriate person acting on the members behalf

You have the responsibility to

x Choose a participating primary care physician if required by your health benefit plan x Treat all health care professionals and staff with courtesy and respect x Keep scheduled appointments with your doctor and call the doctorrsquos office if you have a delay or cancellation x Read and understand to the best of your ability all materials concerning your health benefits or ask for help if you

need it x Understand your health problems and participate along with your health care professionals and providers in

developing mutually agreed upon treatment goals to the degree possible x Supply to the extent possible information that we andor your health care professionals and providers need in order

to provide care x Follow the plans and instructions for care that you have agreed on with your health care professional and provider x Tell your health care professional and provider if you do not understand your treatment plan or what is expected of

you x Follow all health benefit plan guidelines provisions policies and procedures x Let our Customer Service Department know if you have any changes to your name address or family members

covered under your policy x Provide us with accurate and complete information needed to administer your health benefit plan including other

health benefit coverage and other insurance benefits you may have in addition to your coverage with us We are committed to providing quality benefits and customer service to our members Benefits and coverage for services provided under the benefit program are governed by the Subscriber Agreement and not by this Member Rights and Responsibilities statement

66 wwwempirebluecom

Definitions

Refer to these definitions to help you better understand your coverage Need more help Additional terms and definitions can be viewed at wwwempirebluecom

Adverse Determination A communication from Empirersquos Medical Management that reduces or denies benefits

Annual Out-of-Pocket Limit The most you pay during a Benefit Period in cost sharing before your Plan begins to pay 100 of the Maximum Allowed Amount for Covered Services The Annual Out-of-Pocket Limit does not include your Premium amounts over the Maximum Allowed Amount or charges for services that your Plan does not cover The Annual Out-of-Pocket Limit may consist of Deductibles Coinsurance andor Copayments Please see the ldquoYour Benefits At A Glancerdquo section for cost shares that apply to Your Plan

Authorized Services See ldquoprecertified servicesrdquo

Co-payment The fee you pay for office visits and certain covered services when you use in-network providers The plan then pays 100 of remaining covered expenses

Covered Services The services for which Empire provides benefits under the terms of your contract For example Empire covers one in-network annual physical exam

Deductible The dollar amount you must pay each calendar year before your plan pays benefits for covered out-of-network services If you have family coverage once the first family member meets the individual deductible the plan will pay benefits for that family member However the benefits for other family members will not be paid until two or more eligible family members meet the family deductible Once the family deductible is met your PPO plan will pay benefits for covered out-of-network services for the remainder of the year for all eligible family members The exception to this rule is a common accident benefit ndash if two or more family members are injured in the same accident and require medical care the family must meet only one individual deductible

HospitalFacility For purposes of certifying inpatient services a hospital or facility must be a fully licensed acute-care general facility that has all of the following on its own premises

x A broad scope of major surgical medical therapeutic and diagnostic services available at all times to treat almost all illnesses accidents and emergencies

x 24-hour general nursing service with registered nurses who are on duty and present in the hospital at all times x A fully-staffed operating room suitable for major surgery together with anesthesia service and equipment The

hospital must perform major surgery frequently enough to maintain a high level of expertise with respect to such surgery in order to ensure quality care

x Assigned emergency personnel and a ldquocrash cartrdquo to treat cardiac arrest and other medical emergencies x Diagnostic radiology facilities x A pathology laboratory x An organized medical staff of licensed doctors

For pregnancy and childbirth services the definition of ldquohospitalrdquo includes any birthing center that has a participation agreement with either Empire or another Blue Cross andor Blue Shield plan

For physical therapy purposes the definition of a ldquohospitalrdquo may include a rehabilitation facility either approved by Empire or participating with Empire or another Blue Cross andor Blue Shield plan other than specified above

For kidney dialysis treatment a facility in New York State qualifies for in-network benefits if the facility has an operating certificate issued by the New York State Department of Health and participates with Empire or another Blue Cross andor Blue Shield plan In other states the facility must participate with another Blue Cross andor Blue Shield plan and be certified by the state using criteria similar to New Yorkrsquos Out-of-network benefits will be paid only for non-participating facilities that have an appropriate operating certificate For behavioral healthcare purposes the definition of ldquohospitalrdquo may include a facility that has an operating certificate issued by the Commissioner of Mental Health under Article 31 of the New York Mental Hygiene Law a facility operated by the Office of Mental Health or a facility that has a participation agreement with Empire to provide mental and behavioral healthcare

wwwempirebluecom 67

services For alcohol andor substance abuse received out-of-network a facility in New York State must be certified by the Office of Alcoholism and Substance Abuse Services A facility outside of New York State must be approved by the Joint Commission on the Accreditation of Healthcare Organizations For certain specified benefits the definition of a ldquohospitalrdquo or ldquofacilityrdquo may include a hospital hospital department or facility that has a special agreement with Empire Empire does not recognize the following facilities as hospitals nursing or convalescent homes and institutions rehabilitation facilities (except as noted above) institutions primarily for rest or for the aged spas sanitariums infirmaries at schools colleges or camps

In-Network Benefits Benefits for covered services delivered by in-network providers and suppliers Services provided must fall within the scope of their individual professional licenses

In-Network ProviderSupplier A doctor other professional provider or durable medical equipment home health care or home infusion supplier who

x Is in Empirersquos PPO network x Is in the PPO network of another Blue Cross andor Blue Shield plan x Has a negotiated rate arrangement with another Blue Cross andor Blue Shield plan that does not have a PPO network

Itemized Bill A bill from a provider hospital or ambulance service that gives information that Empire needs to settle your claim Provider and hospital bills will contain the patientrsquos name diagnosis and date and charge for each service performed A provider bill will also have the providerrsquos name and address and descriptions of each service while a hospital bill will have the subscriberrsquos name and address the patientrsquos date of birth and the plan holderrsquos Empire identification number Ambulance bills will include the patientrsquos full name and address date and reason for service total mileage traveled and charges

Lifetime Maximum The maximum amount of benefits your plan will pay for covered expenses over the course of your lifetime

Maximum Allowed Amount (MAA) The maximum dollar amount of reimbursement for Covered Services Please see the Maximum Allowed Amount Reimbursement for Covered Services section for additional information

Medical Necessity We Cover benefits described in this Booklet as long as the health care service procedure treatment test device Prescription Drug or supply (collectively ldquoservicerdquo) is Medically Necessary The fact that a Provider has furnished prescribed ordered recommended or approved the service does not make it Medically Necessary or mean that We have to Cover it We may base Our decision on a review of x Your medical records x Our medical policies and clinical guidelines x Medical opinions of a professional society peer review committee or other groups of Physicians x Reports in peer-reviewed medical literature x Reports and guidelines published by nationally-recognized health care organizations that include supporting scientific data x Professional standards of safety and effectiveness which are generally-recognized in the United States for diagnosis care or

treatment x The opinion of Health Care Professionals in the generally-recognized health specialty involved x The opinion of the attending Providers which have credence but do not overrule contrary opinions Services will be deemed Medically Necessary only if x They are clinically appropriate in terms of type frequency extent site and duration and considered effective for Your

illness injury or disease x They are required for the direct care and treatment or management of that condition x Your condition would be adversely affected if the services were not provided x They are provided in accordance with generally accepted standards of medical practice x They are not primarily for the convenience of You Your family or Your Provider x They are not more costly than an alternative service of sequence of services that is at least as likely to produce equivalent

therapeutic or diagnostic results x When setting or place of service is part of the review services that can be safely provided to You in a lower cost setting will

not be Medically Necessary if they are performed in a higher cost setting For example we will not provide coverage for an inpatient admission for surgery if the surgery could have been performed on an outpatient basis or infusion of a specialty

68 wwwempirebluecom

drug provided in the outpatient department of a hospital if the drug could be provided in the physicianrsquos office of the home setting

Non-Participating HospitalFacility A hospital or facility that does not have a participation agreement with Empire or another Blue Cross andor Blue Shield plan to provide services to persons covered under Empirersquos PPO contract Or a hospital or facility that does not accept negotiated rate arrangements as payment in full in a plan area without a PPO network

Operating Area Empire operates in the following 28 eastern New York State counties Albany Bronx Clinton Columbia Delaware Dutchess Essex Fulton Greene Kings Montgomery Nassau New York Orange Putnam Queens Rensselaer Richmond Rockland Saratoga Schenectady Schoharie Suffolk Sullivan Ulster Warren Washington Westchester

Out-of-Network Benefits Reimbursement for covered services provided by out-of-network providers and suppliers Out-of-network benefits are generally subject to a deductible and coinsurance and therefore have higher out-of-pocket costs

Out-of-Network Deductible and Coinsurance Out-of-network benefits for all services are paid after you meet an individual or family out-of-network deductible Once your out-of-network deductible is met you and the plan share the cost You and the plan each pay a percentage called coinsurance of Empirersquos maximum allowed amount for the out-of-network service You are responsible for any amounts not covered or which are in excess of the allowed amount You pay your out-of-network coinsurance up to an annual out-of-pocket limit Once you meet your annual out-of-network out-of-pocket limit you will not be required to pay coinsurance but you will be responsible to pay the difference between the providerrsquos actual charge and Empirersquos allowed amount This is not applied to the deductible and coinsurance amounts Refer to Your Benefits at a Glance section for your out-of-network deductible coinsurance and out-of-pocket limit amounts

Out-of-Network ProvidersSuppliers A doctor other professional provider or durable medical equipment home health care or home infusion supplier who

x Is not in Empirersquos PPO network x Is not in the PPO network of another Blue Cross andor Blue Shield plan x Does not have a negotiated rate with another Blue Cross andor Blue Shield plan

Outpatient Surgery See ldquosame-day surgeryrdquo

Participating HospitalFacility A hospital or facility that

x Is in Empirersquos PPO network x Is in the PPO network of another Blue Cross andor Blue Shield plan x Has a negotiated rate arrangement with another Blue Cross andor Blue Shield plan that does not have a PPO network

Plan Administrator The person who has certain authority concerning the health plans such as plan management including deciding questions of eligibility for participation andor the administration of plan assets Empire is not the Plan Administrator To identify your Plan Administrator contact your employer or health plan sponsor

Precertified Services Services that must be coordinated and approved by Empirersquos Medical Management or Behavioral Healthcare Management Programs to be fully covered by your plan Failure to precertify may result in a reduction or denial of benefits

Provider A hospital or facility (as defined earlier in this section) or other appropriately licensed or certified professional healthcare practitioner Empire will pay benefits only for covered services within the scope of the practitionerrsquos license For behavioral healthcare purposes ldquoproviderrdquo includes care from psychiatrists psychologists or licensed clinical social workers providing psychiatric or psychological services within the scope of their practice including the diagnosis and treatment of mental and behavioral disorders Social workers must be licensed by the New York State Education Department or a comparable organization in another state and have three years of post-degree supervised experience in psychotherapy and an additional three years of post-licensure supervised experience in psychotherapy

wwwempirebluecom 69

For maternity care purposes ldquoproviderrdquo includes a certified nurse-midwife affiliated with or practicing in conjunction with a licensed facility and whose services are provided under qualified medical direction

Same-Day Surgery Same-day ambulatory or outpatient surgery is surgery that does not require an overnight stay in a hospital

Treatment Maximums Maximum number of treatments or visits for certain conditions Maximums for in-network and out-of-network services are combined For example if the plan has a limit of 30 visits on a covered expense you would reach the limit if you had 17 visits in-network and 13 visits out-of-network

70 wwwempirebluecom

AudioHealth Library Topics Following is a list of some of our most popular health-related audiotape topics that you can listen to free of charge 24 hours a day seven days a week when you call 247 NurseLine at 1-877-TALK-2RN (825-5276) See the 360˚ Health section for more information on the 247 NurseLine and instructions on how to listen to the tapes These are our most requested audiotapes If you do not see the topic that interests you just ask one of the NurseLine nurses

Abdominal Problems 1600 Appendicitis 1451 Constipation 1618 Crohnrsquos Disease 1260 Dehydration 1452 Diarrhea 1605 Diverticulosis and Diverticulitis 1402 Food Poisoning 1608 Gallbladder Disease 2154 Gallbladder Surgery 1612 Gastroesophageal Reflux Disease 1610 Heartburn 1952 Hepatitis 1403 Hernia 1603 Inflammatory Bowel Disease 1611 Irritable Bowel Syndrome 2576 Kidney Stones 1462 Nausea and Vomiting 1609 Rectal Problems 1613 Ulcers 2257 Urinary Incontinence in Women 1291 Urinary Tract Infections

Allergies 1000 Allergies 2770 Drug Allergies 1002 Food Allergies 1007 What About Allergy Shots

Back and Neck Pain 1450 Low Back Pain 1463 Herniated Disk 2174 Low Back Problems Surgery for 1457 Neck Pain

Bone Muscle and Joint Problems 1030 Arthritis 1780 Bunions 2103 Bursitis and Tendon Injury 1781 Calluses and Corns 2104 Carpal Tunnel Syndrome 1038 Fibromyalgia 1039 Gout 1784 Heel Spurs 1031 Juvenile Rheumatoid Arthritis 1033 Lupus

2106 Muscle Cramps and Leg Pain 2259 Osteoarthritis 1032 Osteoporosis 1034 Rheumatoid Arthritis 2169 Rotator Cuff 1456 Sports Injuries 2105 Strains Sprains Fractures and Dislocations 2151 Surgery for Carpal Tunnel Syndrome 1461 TM Disorder

Cancer 1105 Cancer Pain 1110 Colon Polyps 1113 Colorectal Cancer 1120 Womenrsquos Cancer 1124 Lung Cancer

Chest Respiratory and Circulatory Problems 1981 Asthma in Teens and Adults 1908 Atrial Fibrillation (irregular heartbeats) 1983 Bronchitis 1915 Cardiac Rehabilitation 1903 Causes of Heart Attack 1900 Chest Pain 1976 Chronic Obstructive Pulmonary Disease (COPD) 1400 Colds 1907 Heart Failure 1980 Emphysema 1455 Fever 1904 Heart Attack Prevention 1401 Influenza (Flu) 1648 Laryngitis 1910 Mitral Valve Prolapse 1911 Pacemakers 1986 Pneumonia 1406 Sinusitis 1459 Sore Throat and Strep Throat 1081 Stroke Rehabilitation 1460 Swollen Lymph Nodes 1912 Varicose Veins 1407 Viral and Bacterial Infection

wwwempirebluecom 71

Chronic Conditions 1060 ALS (Lou Gehrigrsquos Disease) 1061 Alzheimerrsquos Disease 1950 Chronic Fatigue Syndrome 2570 Chronic Kidney Disease 1063 Epilepsy 1953 Hepatitis B 1909 High Blood Pressure 1832 High Cholesterol 2623 Iron Deficiency Anemia 1959 Living with HIV Infection 1065 Multiple Sclerosis 1066 Parkinsonrsquos Disease 1512 Prediabetes 2550 Thyroid Problems 1508 Type 1 Diabetes 1500 Type 2 Diabetes 1501 Type 2 Diabetes Living with Complications 1502 Type 2 Diabetes Living with the Disease 1503 Type 2 Diabetes Recently Diagnosed

Ear Nose and Throat 1516 Diabetic Retinopathy 1453 Dizziness and Vertigo 1264 Ear Infections 1640 Earwax 1646 Hearing Loss 1641 Inner Ear Infection (Labrynthitis) 1644 Menierersquos Disease 1643 Swimmerrsquos Ear 1650 Tonsillitis

Eye Problems 1700 Eye Problems 2152 Cataract Surgery 1709 Cataracts 1710 Color Blindness 1703 Contact Lens Care 1708 Eye Infections 1705 Eye Injuries 1717 Floaters and Flashes 1712 Glaucoma 1711 Macular Degeneration 1716 Laser Surgery for Nearsightedness 1713 Strabismus 1707 Styes 1702 Vision Tests

First Aid and Emergencies 1750 Animal and Human Bites 1761 Burns 1255 Choking 1762 Cuts 2337 Frostbite 1901 Heart Attack 1759 Heat Exhaustion and Heat Stroke 2256 Hypothermia 2203 Importance of CPR Instructions 1751 Insect and Spider Bites and Stings 1458 Nosebleeds 1763 Poisoning 1764 Puncture Wounds 1766 Removing Splinters 1752 Snake Bites 1067 Stroke 1754 Tick Bites

Headaches and Nervous System Problems 1062 Bellrsquos Palsy 1515 Diabetic Neuropathy 1068 Guillain-Barre Syndrome 1064 Encephalitis 1405 Migraine Headaches 1404 Tension Headaches

Home Health Medicines and Supplies 2000 Bulking Agents and Laxatives 2007 Cold and Allergy Remedies 2003 Cough Preparations 2002 Decongestants 1270 How to Take a Temperature 2001 Pain Relievers 1758 Self-Care Supplies

Infant and Child Health 1250 ADHD 1251 Bed-wetting 2753 Bottle-feeding 1254 Chickenpox 1278 Childhood Rashes 1256 Circumcision 1257 Colic 1258 Croup 1261 Diaper Rash

72 wwwempirebluecom

Infant and Child Health

1080 Dyslexia 2436 Fetal Alcohol Syndrome 1253 Fever Age 3 and Younger 1267 Fifth Disease 1268 Growth and Development of the Newborn 1269 Hand-Foot-Mouth Disease 1837 Healthy Eating for Children 1272 Impetigo 1274 Measles 1275 Mumps 1280 Pinworms 1259 Reyersquos Syndrome 1283 Roseola

Medical Tests and Procedures 1506 Home Blood Sugar Monitoring 1532 Exercise Electrocardiography 1533 Complete Blood Count (CBC) 1534 Chest X-ray 1535 Chorionic Villus Sampling 1536 CT Scan of the Body 1537 Electroencephalogram 1538 Electrocardiogram 1539 Electromyography (EMG) 1540 Barium Enema 1541 Upper Gastrointestinal (GI) Series 1542 Magnetic Resonance Imaging 1546 Lung Function Tests

1284 Rubella (German Measles) 1287 Sudden Infant Death Syndrome (SIDS) 1288 Teething 1247 Temper Tantrums 1292 Thrush 1289 Thumb-Sucking 1290 Toilet Training 1293 Urinary Tract Infections in Children

Infectious Diseases 1408 Avian Influenza (Bird Flu) 1951 Infectious Mononucleosis 1956 Tuberculosis 1965 West Nile Virus

Living Healthy 1279 Immunizations 1295 Health Screenings 1830 Living a Balanced Lifestyle 1831 Guidelines for Eating Well 1833 Be Physically Active 1834 Healthy Weight 1835 Mind-Body Connection 1838 Alcohol and Drug Problems 1841 Be Tobacco-Free 1846 Managing Stress 1853 Healthy Snacks 1964 Relaxation Skills 2204 Accident and Injury Prevention 2428 Treatment for Alcohol Use Problems 2435 Teen Alcohol and Drug Abuse

1547 Abdominal Ultrasound 2155 Cystoscopy 2156 Dilation and Curettage 2157 Episiotomy 2158 Surgery for Hemorrhoids 2159 Hernia Surgery 2160 Hip Replacement Surgery 2162 Arthroscopy 2163 Knee Replacement Surgery 2164 Laparoscopy 2165 Ear Tubes 2171 Tonsillectomy and Adenoidectomy 2503 Shared Decisions about Surgery

Menrsquos Health 1128 Prostate Cancer 1545 Prostate-Specific Antigen Test (PSA Test) 2031 Hair Loss 2034 Benign Prostatic Hyperplasia (Enlarged Prostate) 2036 Testicular Problems 2167 TURP for BPH

wwwempirebluecom 73

Mental Health Problems and Mind-Body Wellness 1069 Bipolar Disorder 1070 Schizophrenia 1071 Dementia 1230 Domestic Violence 1240 Child Maltreatment 1845 Stress Management 2051 Obsessive-compulsive Disorder 2052 Eating Disorders 2055 Panic Attacks and Panic Disorder 2057 Depression 2059 Grief 2063 Social Anxiety Disorder 2066 Suicide

Partnership with your doctor 1201 Patients Bill of Rights 1202 Caregiver Secrets 1800 Skills for Making Wise Health Decisions 1801 Work in Partnership with your Doctor 1802 Finding a Doctor Who Will be a Partner

2352 Sunburn 2353 Warts

Sleeping Disorders 2400 Sleep Problems 2403 Sleep Apnea 2406 Snoring

Womenrsquos Health 1107 Breast Health 1111 Ovarian Cancer 1112 Polycystic Ovary Syndrome 1211 Multiple Pregnancy Twins or More 1504 Gestational Diabetes 1531 Breast Biopsy 1544 Pelvic Exam and Pap Test 1548 Ultrasound for Normal Pregnancy 2312 Pelvic Inflammatory Disease 2426 Pregnancy Precautions During 2640 Bacterial Vaginosis 2643 Yeast Infections 2650 Menopause

Senior Health 1836 Seniors Staying Active and Fit 2004 Medication Problems in Seniors 2006 Medications and Older Adults 2240 Hospice Care 2245 Care at the End of Life 2251 Nutrition for Older Adults 2261 Skin and Nail Problems in Seniors

Skin Problems 1129 Skin Cancer 1273 Lice and Scabies 1755 Blisters 1785 Ingrown Toenails 2330 Acne 2332 Boils 2333 Cold Sores 2334 Dandruff 2336 Atopic Dermatitis 2338 Hives 2343 Rashes 2344 Psoriasis 2346 Fungal Infections 2349 Shingles

2651 Hormone Therapy 2670 Missed or Irregular Periods 2672 Endometriosis 2673 Uterine Fibroids 2674 Hysterectomy 2675 Bleeding Between Periods 2677 Functional Ovarian Cysts 2678 Menstrual Cramps 2679 Dsyfuntional Uterine Bleeding 2680 Toxic Shock Syndrome 2700 How to Make a Healthy Baby 2701 Home Pregnancy Test 2704 Danger signs during pregnancy 2705 Normal Pregnancy 2706 Symptoms and Stages of Labor 2708 Diet During Pregnancy 2709 Exercise During Pregnancy 2710 Rubella and Pregnancy 2714 Amniocentesis 2717 Miscarriage 2719 Stretch Marks 2720 Cesarean Section 2723 Pelvic Organ Prolaps 2724 Premenstrual Syndrome

74 wwwempirebluecom

Womenrsquos Health 2725 Pregnancy Symptoms and Stages of 2750 Postpartum Depression 2751 Breast Feeding 2752 Complications after delivery 2754 Labor Delivery and Postpartum Period 2755 Mastitis While Breast-Feeding 2756 Rh Sensitization During Pregnancy 2757 Weaning

Additional topics that are not listed are also available

wwwempirebluecom 75

2016 AMENDMENT This Amendment changes provisions in or adds provisions to your Benefit Booklet including any affected riders endorsements or other amendments thereto issued by Empire upon your Planrsquos renewal on or after January 1 2016 Except as otherwise provided for in this Amendment the provisions herein apply to all persons covered under the Benefit Booklet (ldquoMembersrdquo) All of the terms conditions and limitations of the Benefit Booklet to which this Amendment is attached also apply to this Amendment except where they are specifically changed by this Amendment A References to ldquo360deg Healthreg Empirersquos Health Services Programsrdquo are changed to ldquoHealth and

Wellness Solutionsrdquo B The following is added to the Assignment of Benefits provision

Any purported assignment of benefits shall be void Any purported assignee of benefits shall acquire no rights by reason of any such purported assignment

C The following revisions apply to your Ambulatory Surgery benefit

a References to Ambulatory Surgery are hereby deleted and replaced with the following term

Same Day surgery Same-day or outpatient surgery is surgery performed in a hospital or other facility that does not require an overnight stay For same-day surgery the definition of ldquohospitalrdquo may include a free-standing ambulatory surgical facility that has a participation agreement with either Empire or another Blue Cross andor Blue Shield plan ldquoFacilityrdquo does not include a providerrsquos office

b i The following provision is deleted from your Benefit Booklet

You are also covered for same-day (outpatient or ambulatory) hospital services such as chemotherapy radiation therapy cardiac rehabilitation and kidney dialysis Same-day surgical services or invasive diagnostic procedures are covered when they

x Are performed in a same day or hospital outpatient surgical facility x Require the use of both surgical operating and postoperative recovery rooms x May require either local or general anesthesia x Do not require inpatient hospital admission because it is not appropriate or medically

necessary and x Would justify an inpatient hospital admission in the absence of a same-day surgery program

ii The following provision is added to your Benefit Booklet You are also covered for same-day (outpatient or ambulatory) hospital services such as chemotherapy radiation therapy cardiac rehabilitation and kidney dialysis Same-day surgical services or invasive diagnostic procedures are covered when they

x Are performed in a hospital outpatient facility x Require the use of both surgical operating and postoperative recovery rooms x May require either local or general anesthesia x Do not require inpatient hospital admission because it is not appropriate or medically

necessary and x Would justify an inpatient hospital admission in the absence of a same-day surgery program

D The following defined terms are added to your Benefit Booklet a Health Care Professional An appropriately licensed registered or certified Physician

dentist optometrist chiropractor psychologist social worker podiatrist physical therapist occupational therapist midwife speech-language pathologist audiologist pharmacist behavior analyst or any other licensed registered or certified Health Care Professional under Title 8 of the New York Education Law (or other comparable state law if applicable) that the New York Insurance Law requires to be recognized who

76 wwwempirebluecom

charges and bills patients for Covered Services The Health Care Professionalrsquos services must be rendered within the lawful scope of practice for that type of Provider in order to be covered under this benefit plan

b Provider A Physician Health Care Professional or Facility licensed registered certified or accredited as required by law A Provider also includes a vendor or dispenser of diabetic equipment and supplies durable medical equipment medical supplies or any other equipment or supplies that are Covered under this benefit plan that is licensed registered certified or accredited as required by law

wwwempirebluecom 77

2017 AMENDMENT

This Amendment changes provisions in or adds provisions to your Benefit Booklet including any affected riders endorsements or other amendments thereto issued by Empire upon your Planrsquos renewal on or after January 1 2017 Except as otherwise provided for in this Amendment the provisions herein apply to all persons covered under the Benefit Booklet (ldquoMembersrdquo) All of the terms conditions and limitations of the Benefit Booklet to which this Amendment is attached also apply to this Amendment except where they are specifically changed by this Amendment

A The following is added to the Introduction section of your Benefit Booklet Your Employer has agreed to be subject to the terms and conditions of Empirersquos provider agreements which may include precertification and utilization management requirements timely filing limits and other requirements to administer the benefits under this Plan

B The BlueCard andor Inter-Plan Program provision language is hereby deleted and

replaced with the following Inter-Plan Programs

1 Out-of-Area Services We have a variety of relationships with other Blue Cross andor Blue Shield Licensees

Generally these relationships are called ldquoInter-Plan Arrangementsrdquo These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross Blue Shield Association (ldquoAssociationrdquo) Whenever You access healthcare services outside the geographic area We serve (the ldquoEmpire Service Areardquo) the claim for those services may be processed through one of these Inter-Plan Arrangements The Inter-Plan Arrangements are described below When You receive care outside of the Empire Service Area You will receive it from one of two kinds of Providers Most Providers (ldquoParticipating Providersrdquo) contract with the local Blue Cross andor Blue Shield Plan in that geographic area (ldquoHost Bluerdquo) Some Providers (ldquoNon-Participating Providersrdquo) donrsquot contract with the Host Blue We explain below how We pay both kinds of Providers Inter-Plan Arrangements Eligibility ndash Claim Types Most claim types are eligible to be processed through Inter-Plan Arrangements as described above Examples of claims that are not included are prescription drugs that You obtain from a pharmacy and most dental or vision benefits

2 BlueCardreg Program Under the BlueCardreg Program when You receive Covered Services within the geographic area served by a Host Blue We will still fulfill Our contractual obligations But the Host Blue is responsible for (a) contracting with its Providers and (b) handling its interactions with those Providers When You receive Covered Services outside the Empire Service Area and the claim is processed through the BlueCard Program the amount You pay is calculated based on the lower of

x The billed charges for Covered Services or x The negotiated price that the Host Blue makes available to Us

Often this ldquonegotiated pricerdquo will be a simple discount that reflects an actual price that the Host Blue pays to the Provider Sometimes it is an estimated price that takes into account special arrangements with that Provider Sometimes such an arrangement may be an average price based on a discount that results in expected average savings for services provided by similar types of Providers Estimated and average pricing arrangements may also involve types of settlements incentive payments andor other credits or charges Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims as noted above However such adjustments will not affect the price We used for Your claim because they will not be applied after a claim has already been paid

3 Special Cases Value-Based Programs BlueCardreg Program If You receive Covered Services under a value-based program inside a Host Bluersquos service area You will not be responsible for paying any of the Provider Incentives risk-sharing andor Care Coordinator Fees that are a part of such an arrangement except when a Host Blue passes these fees to Empire through average pricing or fee schedule adjustments Additional information is available upon request

78 wwwempirebluecom

4 Inter-Plan Programs FederalState TaxesSurchargesFees Federal or state laws or regulations may require

a surcharge tax or other fee If applicable We will include any such surcharge tax or other fee as part of the claim charge passed on to You

5 Non-Participating Providers Outside Our Service Area a Allowed Amounts and Member Liability Calculation When Covered Services are provided outside of

Empirersquos Service Area by Non-Participating Providers We may determine benefits and make payment based on pricing from either the Host Blue or the pricing arrangements required by applicable state or federal law In these situations the amount You pay for such services as Deductible Copayment or Coinsurance will be based on that allowed amount Also You may be responsible for the difference between the amount that the Non-Participating Provider bills and the payment We will make for the Covered Services as set forth in this paragraph Federal or state law as applicable will govern payments for out-of-network emergency services

b Exceptions In certain situations We may use other pricing methods such as billed charges the pricing We would use if the healthcare services had been obtained within the Empire Service Area or a special negotiated price to determine the amount We will pay for services provided by Non-Participating Providers In these situations You may be liable for the difference between the amount that the Non-Participating Provider bills and the payment We make for the Covered Services as set forth in this paragraph

6 BlueCard Worldwidereg Program If You plan to travel outside the United States call Member Services to

find out Your BlueCard Worldwide benefits Benefits for services received outside of the United States may be different from services received in the United States Remember to take an up to date health ID card with You When You are traveling abroad and need medical care You can call the BlueCard Worldwide Service Center any time They are available 24 hours a day seven (7) days a week The toll free number is 800-810-2583 Or You can call them collect at 804-673-1177 If You need inpatient hospital care You or someone on Your behalf should contact Us for preauthorization Keep in mind if You need emergency medical care go to the nearest hospital There is no need to call before You receive care How claims are paid with BlueCard Worldwide In most cases when You arrange inpatient hospital care with BlueCard Worldwide claims will be filed for You The only amounts that You may need to pay up front are any Copayment Coinsurance or Deductible amounts that may apply You will typically need to pay for the following services up front

x Doctors services x Inpatient hospital care not arranged through BlueCard Worldwide and x Outpatient services

You will need to file a claim form for any payments made up front

When You need BlueCard Worldwide claim forms You can get international claim forms in the following ways

x Call the BlueCard Worldwide Service Center at the numbers above or x Online at wwwbluecardworldwidecom

You will find the address for mailing the claim on the form

C The Subrogation and Reimbursement provisions are hereby deleted and replaced with the following

Subrogation and Reimbursement These provisions apply when the Plan pays benefits as a result of injuries or illnesses you sustained and you have a right to a Recovery or have received a Recovery from any source A ldquoRecoveryrdquo includes but is not limited to monies received from any person or party any personrsquos or partyrsquos liability insurance uninsuredunderinsured motorist proceeds workerrsquos compensation insurance or fund ldquono-faultrdquo insurance andor automobile medical payments coverage whether by lawsuit settlement or otherwise Regardless of how

wwwempirebluecom 79

you or your representative or any agreements characterize the money you receive as a Recovery it shall be subject to these provisions 1 Subrogation

The Plan has the right to recover payments it makes on your behalf from any party responsible for compensating you for your illnesses or injuries The following apply The Plan has first priority from any Recovery for the full amount of benefits it has paid regardless of whether you are fully compensated and regardless of whether the payments you receive make you whole for your losses illnesses andor injuries You and your legal representative must do whatever is necessary to enable the Plan to exercise the Plans rights and do nothing to prejudice those rights In the event that you or your legal representative fails to do whatever is necessary to enable the Plan to exercise its subrogation rights the Plan shall be entitled to deduct the amount the Plan paid from any future benefits under the Plan The Plan has the right to take whatever legal action it sees fit against any person party or entity to recover the benefits paid under the Plan To the extent that the total assets from which a Recovery is available are insufficient to satisfy in full the Plans subrogation claim and any claim held by you the Plans subrogation claim shall be first satisfied before any part of a Recovery is applied to your claim your attorney fees other expenses or costs The Plan is not responsible for any attorney fees attorney liens other expenses or costs you incur The common fund doctrine does not apply to any funds recovered by any attorney you hire regardless of whether funds recovered are used to repay benefits paid by the Plan

2 Reimbursement

If you obtain a Recovery and the Plan has not been repaid for the benefits the Plan paid on your behalf the Plan shall have a right to be repaid from the Recovery in the amount of the benefits paid on your behalf and the following provisions will apply You must promptly reimburse the Plan from any Recovery to the extent of benefits the Plan paid on your behalf regardless of whether the payments you receive make you whole for your losses illnesses andor injuries Notwithstanding any allocation or designation of your Recovery (eg pain and suffering) made in a settlement agreement or court order the Plan shall have a right of full recovery in first priority against any Recovery Further the Planrsquos rights will not be reduced due to your negligence You and your legal representative must hold in trust for the Plan the proceeds of the gross Recovery (ie the total amount of your Recovery before attorney fees other expenses or costs) to be paid to the Plan immediately upon your receipt of the Recovery You and your legal representative acknowledge that the portion of the Recovery to which the Planrsquos equitable lien applies is a Plan asset Any Recovery you obtain must not be dissipated or disbursed until such time as the Plan has been repaid in accordance with these provisions You must reimburse the Plan in first priority and without any set-off or reduction for attorney fees other expenses or costs The common fund doctrine does not apply to any funds recovered by any attorney you hire regardless of whether funds recovered are used to repay benefits paid by the Plan If you fail to repay the Plan the Plan shall be entitled to deduct any of the unsatisfied portion of the amount of benefits the Plan has paid or the amount of your Recovery whichever is less from any future benefit under the Plan if The amount the Plan paid on your behalf is not repaid or otherwise recovered by the Plan or You fail to cooperate

80 wwwempirebluecom

In the event that you fail to disclose the amount of your settlement to the Plan the Plan shall be entitled to deduct the amount of the Planrsquos lien from any future benefit under the Plan The Plan shall also be entitled to recover any of the unsatisfied portion of the amount the Plan has paid or the amount of your Recovery whichever is less directly from the Providers to whom the Plan has made payments on your behalf In such a circumstance it may then be your obligation to pay the Provider the full billed amount and the Plan will not have any obligation to pay the Provider or reimburse you The Plan is entitled to reimbursement from any Recovery in first priority even if the Recovery does not fully satisfy the judgment settlement or underlying claim for damages or fully compensate you or make you whole

3 Your Duties

You must promptly notify the Plan of how when and where an accident or incident resulting in personal injury or illness to you occurred all information regarding the parties involved and any other information requested by the Plan You must cooperate with the Plan in the investigation settlement and protection of the Plans rights In the event that you or your legal representative fails to do whatever is necessary to enable the Plan to exercise its subrogation or reimbursement rights the Plan shall be entitled to deduct the amount the Plan paid from any future benefits under the Plan You must not do anything to prejudice the Plans rights You must send the Plan copies of all police reports notices or other papers received in connection with the accident or incident resulting in personal injury or illness to you You must promptly notify the Plan if you retain an attorney or if a lawsuit is filed on your behalf You must immediately notify the Plan if a trial is commenced if a settlement occurs or if potentially dispositive motions are filed in a case The Plan Sponsor has sole discretion to interpret the terms of the Subrogation and Reimbursement provision of this Plan in its entirety and reserves the right to make changes as it deems necessary If the covered person is a minor any amount recovered by the minor the minorrsquos trustee guardian parent or other representative shall be subject to this provision Likewise if the covered personrsquos relatives heirs andor assignees make any Recovery because of injuries sustained by the covered person that Recovery shall be subject to this provision The Plan is entitled to recover its attorneyrsquos fees and costs incurred in enforcing this provision The Plan shall be secondary in coverage to any medical payments provision no-fault automobile insurance policy or personal injury protection policy regardless of any election made by you to the contrary The Plan shall also be secondary to any excess insurance policy including but not limited to school andor athletic policies

D Provision language related to Special Enrollment Periods is hereby deleted and replaced

with the following

You Your Spouse or Child can also enroll for coverage within 60 days of the loss of coverage in another group health plan if coverage was terminated because You Your Spouse or Child are no longer eligible for coverage under the other group health plan due to

1 Termination of employment 2 Termination of the other group health plan 3 Death of the Spouse 4 Legal separation divorce or annulment 5 Reduction of hours of employment

wwwempirebluecom 81

6 Employer contributions toward the group health plan were terminated for You or Your Dependentsrsquo coverage or

7 A Child no longer qualifies for coverage as a Child under the other group health plan You Your Spouse or Child can also enroll 60 days from exhaustion of Your COBRA or continuation coverage or if You gain a Dependent or become a Dependent through marriage birth adoption or placement for adoption We must receive notice within 60 days of the loss of coverage The effective date of Your coverage will be the date indicated on the application In addition You Your Spouse or Child can also enroll for coverage within 60 days of the occurrence of one of the following events

1 You or Your Spouse or Child loses eligibility for Medicaid or a state child health plan or 2 You or Your Spouse or Child becomes eligible for Medicaid or a state child health plan

We must receive notice within 60 days of one of these events The effective date of Your coverage will be the date indicated on the application

E The following is added to the Exclusions and Limitations section of Your Benefit Booklet

x Conversion Therapy We do not cover conversion therapy Conversion therapy is any practice by a mental

health professional that seeks to change the sexual orientation or gender identity of a Member under 18 years of age including efforts to change behaviors gender expressions or to eliminate or reduce sexual or romantic attractions or feelings toward individuals of the same sex Conversion therapy does not include counseling or therapy for an individual who is seeking to undergo a gender transition or who is in the process of undergoing a gender transition that provides acceptance support and understanding of an individual or the facilitation of an individualrsquos coping social support and identity exploration and development including sexual orientation-neutral interventions to prevent or address unlawful conduct or unsafe sexual practices provided that the counseling or therapy does not seek to change sexual orientation or gender identity

82 wwwempirebluecom

2018 AMENDMENT

This Amendment changes provisions in or adds provisions to your Benefit Booklet including any affected riders endorsements or other amendments thereto issued by Empire upon your Planrsquos renewal on or after January 1 2018 Except as otherwise provided for in this Amendment the provisions herein apply to all persons covered under the Benefit Booklet (ldquoMembersrdquo) All of the terms conditions and limitations of the Benefit Booklet to which this Amendment is attached also apply to this Amendment except where they are specifically changed by this Amendment

A The following is added to the listing of services requiring prior authorization or precertification x Genetic Testing

B The BlueCard andor Inter-Plan Program provision language is hereby deleted and replaced with

the following Inter-Plan Programs 1 Out-of-Area Services We have a variety of relationships with other Blue Cross andor Blue

Shield Licensees Generally these relationships are called ldquoInter-Plan Arrangementsrdquo These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross Blue Shield Association (rdquoAssociationrdquo) Whenever You access healthcare services outside of the geographic area We serve (the ldquoEmpire Service Areardquo) the claims for these services may be processed through one of these Inter-Plan Arrangements The Inter-Plan Arrangements are described below

When You receive care outside of the Empire Service Area You will receive it from one of two kinds of Providers Most Providers (ldquoParticipating Providersrdquo) contract with the local Blue Cross andor Blue Shield Plan in that geographic area (ldquoHost Bluerdquo) Some Providers (ldquoNon-Participating Providersrdquo) donrsquot contract with the Host Blue We explain below how We pay both kinds of Providers

Inter-Plan Arrangements Eligibility ndash Claim Types Most claim types are eligible to be processed through Inter-Plan Arrangements as described above Examples of claims that are not included are prescription drugs that You obtain from a pharmacy and most dental or vision benefits

2 BlueCardreg Program Under the BlueCardreg Program when You receive Covered Services within the geographic area served by a Host Blue We will still fulfill Our contractual obligations But the Host Blue is responsible for (a) contracting with its Providers and (b) handling its interactions with those Providers

When You receive Covered Services outside the Empire Service Area and the claim is processed through the BlueCard Program the amount You pay is calculated based on the lower of

x The billed charges for Covered Services or x The negotiated price that the Host Blue makes available to Us

Often this ldquonegotiated pricerdquo will be a simple discount that reflects an actual price that the Host Blue pays to the Provider Sometimes it is an estimated price that takes into account special arrangements with that Provider Sometimes such an arrangement may be an average price based on a discount that results in expected average savings for services provided by similar types of Providers Estimated and average pricing arrangements may also involve types of settlements incentive payments andor other credits or charges Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims as noted above However such adjustments will not affect the price We used for Your claim because they will not be applied after a claim has already been paid

3 Special Cases Value-Based Programs BlueCardreg Program If You receive Covered Services under a value-based program inside a Host Bluersquos service area You will not be responsible for paying any of the Provider Incentives risk-sharing andor Care Coordinator Fees that are a part

wwwempirebluecom 83

of such an arrangement except when a Host Blue passes these fees to Empire through average pricing or fee schedule adjustments

4 Inter-Plan Programs FederalState TaxesSurchargesFees Federal or state laws or regulations may require a surcharge tax or other fee If applicable We will include any such surcharge tax or other fee as part of the claim charge passed on to You

5 Non-Participating Providers Outside Our Service Area

a Allowed Amounts and Member Liability Calculation When Covered Services are provided outside of Empirersquos Service Area by non-participating providers We may determine benefits and make payment based on pricing from either the Host Blue or the pricing arrangements required by applicable state or federal law In these situations the amount You pay for such services as Deductible Copayment or Coinsurance will be based on that allowed amount Also You may be responsible for the difference between the amount that the non-participating provider bills and the payment We will make for the Covered Services as set forth in this paragraph Federal or state law as applicable will govern payments for out-of-network emergency services

b Exceptions In certain situations We may use other pricing methods such as billed charges the pricing We would use if the healthcare services had been obtained within the Empire Service Area or a special negotiated price to determine the amount We will pay for services provided by non-participating providers In these situations You may be liable for the difference between the amount that the non-participating provider bills and the payment We make for the Covered Services as set forth in this paragraph

6 Blue Cross Blue Shield Global Corereg Program If You plan to travel outside the United States

call Member Services to find out Your Blue Cross Blue Shield Global Corereg benefits Benefits for services received outside of the United States may be different from services received in the United States The plan only covers Emergency including ambulance and Urgent Care outside of the United States Remember to take an up to date health ID card with You

When You are traveling abroad and need medical care You can call the Blue Cross Blue Shield Global Corereg Service Center any time They are available 24 hours a day seven (7) days a week The toll free number is 800-810-2583 Or You can call them collect at 804-673-1177

How claims are paid with Blue Cross Blue Shield Global Corereg In most cases when You arrange inpatient hospital care with Blue Cross Blue Shield Global Corereg claims will be filed for You The only amounts that You may need to pay up front are any Copayment Coinsurance or Deductible amounts that may apply You will typically need to pay for the following services up front x Doctors services x Inpatient hospital care not arranged through Blue Cross Blue Shield Global Corereg and x Outpatient services

You will need to file a claim form for any payments made up front

When You need Blue Cross Blue Shield Global Corereg claim forms You can get international claim forms in the following ways x Call the Blue Cross Blue Shield Global Corereg Service Center at the numbers above or x Online atwwwbcbsglobalcorecom

You will find the address for mailing the claim on the form

C The ldquoInitial Decisionsrdquo section of the ldquoHealth Managementrdquo chapter of your benefit booklet is hereby deleted and replaced with the following 5 Preauthorization Reviews

d Non-Urgent Preauthorization Reviews If We have all the information necessary to make a determination regarding a Preauthorization review We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of

84 wwwempirebluecom

receipt of the request

If We need additional information We will request it within fifteen (15) calendar days You or Your Provider will then have 45 calendar days to submit the information If We receive the requested information within 45 days We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of Our receipt of the additional information If all necessary information is not received within 45 days We will make a determination within 15 calendar days of the end of the 45 day period allowed to submit the additional information

e Urgent Preauthorization Reviews With respect to urgent Preauthorization requests if We

have all information necessary to make a determination We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within 72 hours of receipt of the request If We need additional information We will request it within 24 hours You or Your Provider will then have 48 hours to submit the information We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within 48 hours of the earlier of Our receipt of the additional information or the end of the 48-hour period allowed to submit additional information

f Court Ordered Treatment With respect to requests for mental health andor substance use

disorder services that have not yet been provided if You (or Your designee) certify in a format prescribed by the Superintendent of Financial Services that You will be appearing or have appeared before a court of competent jurisdiction and may be subject to a court order requiring such services We will make a determination and provide notice to You (or Your designee) and Your Provider by telephone within 72 hours of receipt of the request Written notification will be provided within three (3) business days of Our receipt of the request Where feasible the telephonic and written notification will also be provided to the court

6 Concurrent Reviews

4 Non-Urgent Concurrent Reviews Utilization Review decisions for services during the course of care (concurrent reviews) will be made and notice provided to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of receipt of all necessary information If We need additional information We will request it within fifteen (15) calendar days of the receipt of the request You or Your Provider will then have 45 calendar days to submit the additional information We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of Our receipt of the additional information or if We do not receive the information within 15 calendar days of the end of the 45-day period allowed to provide the additional information

5 Urgent Concurrent Reviews For concurrent reviews that involve an extension of urgent care if

the request for coverage is made at least 24 hours prior to the expiration of a previously approved treatment We will make a determination and provide notice to You (or Your designee) and Your Provider within 24 hours of receipt of the request If the request for coverage is not made at least 24 hours prior to the expiration of a previously approved treatment We will make a determination and provide written notice to You (or Your designee) and Your Provider within 72 hours of receipt of the request If We need additional information We will request it within 24 hours You or Your Provider will then have 48 hours to submit the information We will make a determination and provide written notice to You (or Your designee) and Your Provider within the earlier of one (1) business day or 48 hours of Our receipt of the information or if We do not receive the information within 48 hours of the end of the 48-hour period

6 Inpatient Substance Use Disorder Treatment Reviews If a request for inpatient substance use disorder treatment is submitted to Us at least 24 hours prior to discharge from an inpatient substance use disorder treatment admission We will make a determination within 24 hours of receipt of the request and We will provide coverage for the inpatient substance use disorder treatment while Our determination is pending

wwwempirebluecom 85

7 Retrospective Reviews If We have all information necessary to make a determination regarding a

retrospective claim We will make a determination and notify You and Your Provider within 30 calendar days of the receipt of the request If We need additional information We will request it within 30 calendar days You or Your Provider will then have 45 calendar days to provide the information We will make a determination and provide notice to You and Your Provider in writing within 15 calendar days of the earlier of Our receipt of the information or the end of the 45-day period

Once We have all the information to make a decision Our failure to make a Utilization Review determination within the applicable time frames set forth above will be deemed an adverse determination subject to an internal Appeal

8 Retrospective Review of Preauthorized Services We may only reverse a preauthorized treatment

service or procedure on retrospective review when x The relevant medical information presented to Us upon retrospective review is materially

different from the information presented during the Preauthorization review x The relevant medical information presented to Us upon retrospective review existed at the

time of the Preauthorization but was withheld or not made available to Us x We were not aware of the existence of such information at the time of the Preauthorization

review and x Had We been aware of such information the treatment service or procedure being

requested would not have been authorized The determination is made using the same specific standards criteria or procedures as used during the Preauthorization review

D Coverage for Online Visits is revised as follows

x Online visits Your coverage includes online physician office visits Covered Services

include a visit with the physician using the internet via a webcam with online chat or voice functions Services are provided by board certified licensed Primary Care Physicians Online visits are not for specialist care Common types of diagnoses and conditions treated online are cough fever headaches sore throat routine child health issues influenza upper respiratory infections sinusitis bronchitis and urinary tract infections when uncomplicated in nature Member Access To begin the online visit log on to wwwlivehealthonlinecom and establish an online account by providing some basic information about You and Your insurance plan Before You connect to a Doctor You will be asked to identify the kind of condition You want to discuss with the Doctor list Your local pharmacy provide information for the credit card You want Your cost share for the visit to be billed to agree to the terms of use and select an available Physician If You are not in New York State when You seek an online visit You will need to check to be sure an online Doctor is available in the state You are in because online Doctors are not available in every state The visit with the Physician will not start until You provide the above information and click ldquoconnectrdquo The visit will be documented in an electronic health record You may access Your records and print them and may email or fax them to Your Primary Care Physician Note about Covered Services Online visits are not meant for the following purposes

x To get reports of normal lab or other test results x To request an office appointment x To ask billing insurance coverage or payment questions x To ask for a referral to a specialist Doctor x To request Preauthorization for a benefit under your health Plan or x To ask the Physician to consult with another Physician

E The following provisions related to Claim Determinations are added to your benefit booklet

1 Claims A claim is a request that benefits or services be provided or paid according to the terms of

this Booklet When You receive services from a Participating Provider You will not need to submit a claim form However if You receive services from a Non-Participating Provider either You or the Provider must file a claim form with Us If the Non-Participating Provider is not willing to file the claim form You will need to file it with Us See the Coordination of Benefits section of this Booklet for

86 wwwempirebluecom

information on how We coordinate benefit payments when You also have health coverage with another plan

2 Notice of Claim Claims for services must include all information designated by Us as

necessary to process the claim including but not limited to Member identification number name date of birth date of service type of service the charge for each service procedure code for the service as applicable diagnosis code name and address of the Provider making the charge and supporting medical records when necessary A claim that fails to contain all necessary information will not be accepted and must be resubmitted with all necessary information Claim forms are available from Us by calling the number on Your ID card or visiting Our website at wwwempirebluecom Completed claim forms should be sent to the address in the How Your Coverage Works section of this Booklet or on Your ID card You may also submit a claim to Us electronically by sending it to the e-mail address in the How Your Coverage Works section of this Booklet on Your ID card or visiting Our website at wwwempirebluecom

3 Timeframe for Filing Claims Claims for services must be submitted to Us for payment within 18

months after You receive the services for which payment is being requested If it is not reasonably possible to submit a claim within the 18 month period You must submit it as soon as reasonably possible

4 Claims for Prohibited Referrals We are not required to pay any claim bill or other demand or

request by a Provider for clinical laboratory services pharmacy services radiation therapy services physical therapy services or x-ray or imaging services furnished pursuant to a referral prohibited by Section 238-a(1) of the New York Public Health Law

5 Claim Determinations Our claim determination procedure applies to all claims that do not relate to

a medical necessity or experimental or investigational determination For example Our claim determination procedure applies to contractual benefit denials If You disagree with Our claim determination You may submit a Grievance pursuant to the Grievance Procedures section of this Booklet

For a description of the Utilization Review procedures and Appeal process for medical necessity or experimental or investigational determinations see the Utilization Review and External Appeal sections of this Booklet

6 Pre-Service Claim Determinations

1 A pre-service claim is a request that a service or treatment be approved before it has been received If We have all the information necessary to make a determination regarding a pre-service claim (eg a covered benefit determination) We will make a determination and provide notice to You (or Your designee) within 15 days from receipt of the claim

If We need additional information We will request it within 15 days from receipt of the claim You will have 45 calendar days to submit the information If We receive the information within 45 days We will make a determination and provide notice to You (or Your designee) in writing within 15 days of Our receipt of the information If all necessary information is not received within 45 days We will make a determination within 15 calendar days of the end of the 45 day period

2 Urgent Pre-Service Reviews With respect to urgent pre-service requests if We have all

information necessary to make a determination We will make a determination and provide notice to You (or Your designee) within 72 hours of receipt of the request If We need additional information We will request it within 24 hours of receipt of the request You will then have 48 hours to submit the information We will make a determination and provide notice to You (or Your designee) within 48 hours of the earlier of Our receipt of the additional information or if information was not received at the end of the 48-hour period allowed to submit the information

7 Post-Service Claim Determinations A post-service claim is a request for a service or treatment that

You have already received If We have all information necessary to make a determination regarding a post-service claim We will make a determination and notify You (or Your designee) within 30 calendar days of the receipt of the claim If We need additional information We will request it within 30 calendar days You will then have 45 calendar days to provide the information We will make a determination and provide notice to You (or Your designee) in writing within 15 calendar days of the

wwwempirebluecom 87

earlier of Our receipt of the information or the end of the 45 day period

F The definition of ldquoProvidersrdquo is revised as follows

x For behavioral healthcare purposes ldquoproviderrdquo includes care from licensed psychiatrists or psychologists licensed clinical social workers licensed mental health counselors licensed marriage and family therapists licensed psychoanalysts licensed psychiatric nurse licensed as a nurse practitioner or clinical nurse specialist or a professional corporation or a university faculty practice corporation thereof Social workers must be licensed by the New York State Education Department or a comparable organization in another state and have three years of post-degree supervised experience in psychotherapy and an additional three years of post-licensure supervised experience in psychotherapy

88 wwwempirebluecom

Get Help In Your Language Curious to know what all this says We would be too Herersquos the English version This notice has important information about your application or benefits Look for important dates You might need to take action by certain dates to keep your benefits or manage costs You have the right to get this information and help in your language for free Call the Member Services number on your ID card for help (TTYTDD 711) Spanish Este aviso contiene informacioacuten importante acerca de su solicitud o sus beneficios Busque fechas importantes Podriacutea ser necesario que actuacutee para ciertas fechas a fin de mantener sus beneficios o administrar sus costos Tiene el derecho de obtener esta informacioacuten y ayuda en su idioma en forma gratuita Llame al nuacutemero de Servicios para Miembros que figura en su tarjeta de identificacioacuten para obtener ayuda (TTYTDD 711) Albanian Ky njoftim peumlrmban informacion teuml reumlndeumlsisheumlm rreth aplikimit ose peumlrfitimeve tuaja Shihni datat kryesore Mund trsquoju nevojitet teuml veproni brenda afateve teuml caktuara peumlr teuml vazhduar teuml peumlrfitoni ose peumlr teuml menaxhuar kostot Keni teuml drejteumln teuml merrni falas ndihmeuml dhe informacion neuml gjuheumln tuaj Peumlr ndihmeuml telefononi numrin e sheumlrbimeve peumlr aneumltareumlt teuml sheumlnuar neuml karteumln tuaj ID (TTYTDD 711) Arabic

محددة مواعید قبل إجراء اتخاذ إلى تحتاج قد المھمة المواعید تتبع على احرص لك المقدمة المزایا أو طلبك حول مھمة معلومات على الإشعار ھذا یحتوي بطاقة على الموجود الأعضاء خدمات برقم الاتصال یرجى جانام بلغتك والمساعدة المعلومات ھذه على الحصول لك یحق التكلفة لإدارة أو بالمزایا للاحتفاظ(TTYTDD711)للمساعدة بك الخاصة التعریف

Bengali আপনার আবেদন বা সবিধার বিষয়ে এই বিজঞপতিটিতে গরতবপরণ তথয রয়েছে গরতবপরণ তারিখগলির জনয দেখন আপনার সবিধাগলি বজায় রাখার জনয বা খরচ নিয়নতরণ করার জনয নিরদিষট তারিখে আপনাকে কাজ করতে হতে পারে বিনামলযে এই তথয পাওয়ার ও আপনার ভাষায় সাহাযয করার অধিকার আপনার আছে সাহাযযের জনয আপনার আইডি কারডে থাকা সদসয পরিষেবা নমবরে কল করন (TTYTDD 711) Chinese 本通知有與您的申請或利益相關的重要資訊請留意重要日期您可能需要在特定日期前採取行動以維護您的利益

或管理費用您有權使用您的語言免費獲得該資訊和協助請撥打您的 ID

卡上的成員服務號碼尋求協助(TTYTDD 711) French Cette notice contient des informations importantes sur votre demande ou votre couverture Vous y trouverez eacutegalement des dates agrave ne pas manquer Il se peut que vous deviez respecter certains deacutelais pour conserver votre couverture santeacute ou vos remboursements Vous avez le droit drsquoacceacuteder gratuitement agrave ces informations et agrave une aide dans votre langue Pour cela veuillez appeler le numeacutero des Services destineacutes aux membres qui figure sur votre carte drsquoidentification (TTYTDD 711) Greek Αυτή η ειδοποίηση περιέχει σημαντικές πληροφορίες για την εφαρμογή σας ή τις παροχές σας Αναζητήστε τις σημαντικές ημερομηνίες Ενδέχεται να χρειαστεί να κάνετε κάποιες ενέργειες μέχρι συγκεκριμένες ημερομηνίες ώστε να διατηρήσετε τις παροχές σας ή να διαχειριστείτε το κόστος Έχετε το δικαίωμα να λάβετε αυτές τις πληροφορίες και αυτήν τη βοήθεια στη γλώσσα σας δωρεάν Καλέστε τον αριθμό του Τμήματος Υπηρεσιών Μέλους (Member Services) που αναγράφεται στην ταυτότητά σας (ID card) για βοήθεια (TTYTDD 711)

wwwempirebluecom 89

Haitian Avi sa a gen enfogravemasyon enpogravetan sou aplikasyon ou an oswa avantaj ou yo Veye dat enpogravetan yo Ou ka bezwen pran aksyon avan segraveten dat pou kenbe avantaj ou yo oswa jere depans ou yo Ou gen dwa pou resevwa enfogravemasyon sa a ak asistans nan lang ou pou gratis Rele nimewo Manm Segravevis la ki sou kat idantifikasyon ou a pou jwenn egraved (TTYTDD 711) Italian Il presente avviso contiene informazioni importanti relative alla domanda da lei presentata o ai benefici a lei riservati Consulti le date importanti riportate Per continuare a usufruire dei benefici o ricevere assistenza per il pagamento delle spese potrebbe dover eseguire determinate azioni entro scadenze specifiche Ha il diritto di ricevere queste informazioni ed eventuale assistenza nella sua lingua senza alcun costo aggiuntivo Per assistenza chiami il numero dedicato ai Servizi per i membri riportato sul suo libretto (TTYTDD 711) Korean 이 공지사항에는 귀하의 신청서 또는 혜택에 대한 중요한 정보가 있습니다 중요 날짜를 살펴 보십시오 혜택을

유지하거나 비용을 관리하기 위해 특정 마감일까지 조치를 취해야 할 수 있습니다 귀하에게는 무료로 이 정보를

얻고 귀하의 언어로 도움을 받을 권리가 있습니다 도움을 얻으려면 귀하의 ID 카드에 있는 회원 서비스 번호로

전화하십시오 (TTYTDD 711) Polish Niniejsze powiadomienie zawiera istotne informacje dotyczące wniosku lub świadczeń Zwroacuteć uwagę na ważne daty Zachowanie świadczeń lub zarządzanie kosztami może wymagać podjęcia dodatkowych działań w konkretnych terminach Masz prawo do bezpłatnego otrzymania stosownych informacji oraz uzyskania pomocy w swoim języku W tym celu skontaktuj się z Działem Obsługi Klienta pod numerem telefonu podanym na karcie identyfikacyjnej (TTYTDD 711) Russian Настоящее уведомление содержит важную информацию о вашем заявлении или выплатах Обратите внимание на контрольные даты Для сохранения права на получение выплат или помощи с расходами от вас может потребоваться выполнение определенных действий в указанные сроки Вы имеете право получить данную информацию и помощь на вашем языке бесплатно Для получения помощи звоните в отдел обслуживания участников по номеру указанному на вашей идентификационной карте (TTYTDD 711) Tagalog May mahalagang impormasyon ang abisong ito tungkol sa inyong aplikasyon o mga benepisyo Tukuyin ang mahahalagang petsa Maaaring may kailangan kayong gawin sa ilang partikular na petsa upang mapanatili ang inyong mga benepisyo o mapamahalaan ang mga gastos May karapatan kayong makuha ang impormasyon at tulong na ito sa ginagamit ninyong wika nang walang bayad Tumawag sa numero ng Member Services na nasa inyong ID card para sa tulong (TTYTDD 711) Urdu

کو اپ لیے کرنےکے منظم کو لاگتوں یا فائدوں اپنے دیکھیے تاریخیں اہم ہے مشتمل پر معلومات اہم میں بارے کے فائدوں یا درخواست کی اپ نوٹس یہ ڈی ائی اپنے لیے کے مدد ہے حق کا کےحصول مدد اور معلومات ان مفت میں زبان اپنی کو اپ ہے ہوسکتی ضرورت کی کرنے اقدام پر تاریخوں بعض (TTYTDD711 )کریں کال کو نمبر سروس ممبر موجود پر کارڈ

90 wwwempirebluecom

Yiddish

מעלדונג דעם אין דאטעס נויטיגע פאר קוקט קאווערידזש אדער אפלעקאציע אייער וועגן אינפארמאציע וויכטיגע האט מעלדונג דעם האט איר קאסט מיט העלפן אדער קאווערידזש געזונט אייערע האלטן צו דעדליינז געוויסע קודם אקציע נעמען דארפן מעגליך וועט איר

קארטל אייער אויף נומער באדינונגען מעמבער די רופט בחינם שפראך אייער אין הילפט און אינפארמאציע דעם באקומען צו רעכט די(TTYTDD711)הילף פאר

Itrsquos important we treat you fairly Thatrsquos why we follow federal civil rights laws in our health programs and activities We donrsquot discriminate exclude people or treat them differently on the basis of race color national origin sex age or disability For people with disabilities we offer free aids and services For people whose primary language isnrsquot English we offer free language assistance services through interpreters and other written languages Interested in these services Call the Member Services number on your ID card for help (TTYTDD 711) If you think we failed to offer these services or discriminated based on race color national origin age disability or sex you can file a complaint also known as a grievance You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator PO Box 27401 Mail Drop VA2002-N160 Richmond VA 23279 Or you can file a complaint with the US Department of Health and Human Services Office for Civil Rights at 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 or by calling 1-800-368-1019 (TDD 1- 800-537-7697) or online at httpsocrportalhhsgovocrportallobbyjsf Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

wwwempirebluecom 1

Welcome Welcome to Empirersquos PPO With Empire BlueCross BlueShield you have access to great coverage flexibility and all the advantages of quality care This benefits book explains exactly how you access healthcare services what your health plan covers and how we can help you make the most of your plan Si necesita ayuda en espantildeol para entender este documento puede solicitarla sin costo adicional llamando al nuacutemero de servicio al cliente que aparece al dorso de su tarjeta de identificacioacuten o en el folleto de inscripcioacuten YOUR PPO ndash A SMART WAY TO GET HEALTHCARE

The Preferred Provider Organization offers a network of healthcare providers available to you through Empire If you think about your town it includes doctors hospitals laboratories and other medical facilities that provide healthcare services ndash thatrsquos what we mean by healthcare ldquoprovidersrdquo Some healthcare providers contract with health plans like Empire BlueCross BlueShield to provide services to members as part of the planrsquos ldquonetworkrdquo

With Empirersquos PPO when you need healthcare services you have a choice Depending on the healthcare service you need you are free to get care from providers participating in your PPO network or you can choose to use outside providers You are covered for medically necessary services no matter which you choose

WHATrsquoS THE EMPIRE PPO ADVANTAGE

When you use Empirersquos PPO network to access healthcare you get

x A comprehensive Web site wwwempirebluecom for fast personalized secure information x Among the largest network of doctors and hospitals in New York State x Providers that are continuously reviewed for Empirersquos high standards of quality x The ability to choose in-network or out-of-network care for most covered services x Minimal out-of-pocket costs for preventive care behavioral healthcare and a wide variety of hospital and medical

services when you stay in-network x Easy to use ndash no claim forms to file when you stay in-network x Coverage for you and your family when traveling or living outside of Empirersquos service area

HOW TO USE THIS GUIDE

This Guide gives you an overview of the features and benefits of your plan Use it as a reference to find out whatrsquos covered what your costs are and how to get healthcare services any time you or a covered family member need them

Yoursquoll find the information you need divided into sections Herersquos a quick reference

IF YOU ARE LOOKING FOR hellip YOUrsquoLL FIND IT IN ON PAGE

x HOW THE PLAN WORKS USING YOUR PPO 6

x WHATrsquoS COVERED COVERAGE 17

x PRECERTIFICATION AND HEALTH INFORMATION HEALTH MANAGEMENT 41

x HOW TO FILE A CLAIM THE MEANING OF HEALTHCARE TERMS AND YOUR LEGAL RIGHTS

DETAILS AND DEFINITIONS 50

This Guide describes only the highlights of your medical coverage It does not attempt to cover all the details Additional details are

provided in the plan documents and insurance andor service contracts which legally govern the plan In the event of any discrepancy between this Guide and the plan documents the plan documents will govern

2 wwwempirebluecom

OUR ROLE IN NOTIFYING YOU There may be times when benefits andor procedures may change We or your employer will notify you of any change in writing Announcements will go directly to you at the address that appears on our records or to your group benefits office

CONFORMITY WITH LAW Any term of this Booklet which is in conflict with any applicable federal law will be amended to conform with the minimum requirements of such law

wwwempirebluecom 3

Manage Your Healthcare Online

REGISTER NOW TO DO IT ON THE WEB

Go to wwwempirebluecom where you can securely manage your health plan 24 hours a day 7 days a week Herersquos what you can do

x Check status of claims x Search for doctors and specialists x Update your member profile x Get health information and tools with My

Health powered by WebMD

x Print plan documents x Receive information through your personal ldquoMessage Centerrdquo x Visit the Pharmacy

Plus much more hellip

HERErsquoS WHAT YOUrsquoLL NEED TO DO

All members of your family 18 or older must register separately x Go to wwwempirebluecom x Click on the Member tab and choose

ldquoRegisterrdquo

x Follow the simple registration instructions

GET PERSONALIZED HEALTH INFORMATION ndash INCLUDING YOUR HEALTH IQ

Click on MY HEALTH from your secure homepage after you register to receive the following features x Take the Health IQ test and compare your score to others in your age group x Find out how to improve your score ndash and your health ndash online x Find out how to take action against chronic and serious illnesses

Get health information for you and your family

YOUR PRIVACY IS PROTECTED

Your information is protected by one of the most advanced security methods available

Register today to experience hassle-free service wwwempirebluecom

4 wwwempirebluecom

Your PPO Guide

Introduction GETTING ANSWERS YOUR WAY 5

Using Your PPO KNOW THE BASICS 6 YOUR BENEFITS AT A GLANCE 10 DOCTORrsquoS SERVICES 17 EMERGENCY CARE 20 MATERNITY CARE 22 HOSPITAL SERVICES 23 DURABLE MEDICAL EQUIPMENT AND SUPPLIES 25 HOME HEALTH CARE 27 PHYSICAL OCCUPATIONAL SPEECH OR VISION THERAPY 28 BEHAVIORAL HEALTHCARE 29 EMPIRE PHARMACY PROGRAM 30 EXCLUSIONS AND LIMITATIONS 40

Health Management EMPIRErsquoS MEDICAL MANAGEMENT PROGRAM 42 NEW MEDICAL TECHNOLOGY 46 CASE MANAGEMENT 46 PREVENTIVE SERVICES 47 WELLNESS PROGRAMS 50

Details and Definitions ELIGIBILITY 51 CLAIMS 52 REIMBURSEMENT FOR COVERED SERVICES 56 COMPLAINTS APPEALS AND GRIEVANCES 59 ENDING AND CONTINUING COVERAGE 63 YOUR RIGHTS AND RESPONSIBILITIES 65 DEFINITIONS 66 AUDIOHEALTH LIBRARY TOPICS 70 2016 AMENDMENT 75 2017 AMENDMENT 77 2018 AMENDMENT 82 GET HELP IN YOUR LANGUAGE 88

wwwempirebluecom 5

Introduction Getting Answers Your Way Empire gives you more choices for contacting us with your customer service questions Use the Internet phone or mail to get the information you need when you need it

ON THE INTERNET Do you have customer service inquiries and need an instant response Visit wwwempirebluecom At Empire we understand that getting answers quickly is important to you Most benefit claims or membership questions can be addressed online quickly simply and confidentially Nervous about using your PC for important healthcare questions or transactions Wersquove addressed that too Just ldquosend us an e-mail

BY TELEPHONE

WHAT WHY WHERE MEMBER SERVICES For questions about your benefits claims

or membership To locate a participating behavioral healthcare provider in your area Precertification of mental health and alcoholsubstance abuse care

1-855-519-9537 TDD for hearing impaired 1-800-682-8786 830 am to 500 pm Monday ndash Friday

ATT SERVICIOS PARA IDIOMAS EXTRANJEROS

Si usted no habla ingleacutes 1-800-342-9816 Por favor permanezca en la liacutenea y espere que la grabacioacuten termine Un representante de servicios a los miembros contestaraacute la liacutenea y le conectaraacute con un traductor 900 am a 500 pm de Lunes ndash Viernes

BLUECARDreg PPO PROGRAM Get network benefits while you are away from home Locate a PPO provider outside Empirersquos network service area

1-800-810-BLUE (2583) wwwbcbscom 24 hours a day 7 days a week

MEDICAL MANAGEMENT PROGRAM Precertification of hospital admissions and certain treatments and procedures

1-855-519-9537 830 am to 500 pm Monday ndash Friday

247 NURSELINE AND AUDIOHEALTH LIBRARY

Speak with a specially trained nurse to get health information and instructions on how to listen to the tapes

1-877-TALK-2RN (825-5276) 24 hours a day 7 days a week

EMPIRErsquoS PHARMACY PROGRAM Information about the program Locate a participating retail pharmacy Obtain a complete drug formulary list

1-800-342-9816 TDD for hearing impaired 1-800-682-8786 700 am to 1000 pm Monday ndash- Friday 900 am to 900 pm Saturday 900 am to 530 pm Sunday

FRAUD HOTLINE Help prevent health insurance fraud 1-800-I-C-FRAUD (423-7283) 900 am to 500 pm Monday ndash Friday

IN WRITING Empire BlueCross BlueShield PPO Member Services PO Box 1407 Church Street Station New York NY 10008-1407

6 wwwempirebluecom

Using Your PPO

Know the Basics The key to using your PPO plan is understanding how benefits are paid Start by choosing in-network or out-of-network services any time you need healthcare Your choice determines the level of benefits you will receive

You can view and print up-to-date information about your plan or request that information be mailed to you by visiting wwwempirebluecom

CHOOSING IN-NETWORK OR OUT-OF-NETWORK SERVICES In-network services are healthcare services provided by a doctor hospital or healthcare facility that has been selected by Empire or another Blue Cross andor Blue Shield plan to provide care to our members When you choose in-network care you get these advantages

x CHOICE ndash You can choose any participating provider from the largest network of doctors and hospitals in New York State or the network of Blue Cross and Blue Shield plans through the BlueCardreg PPO Program

x FREEDOM ndash You do not need a referral to see a specialist so you direct your care x LOW COST ndash Benefits are paid after a co-payment OR deductible and coinsurance payment for office visits and

many other services x BROAD COVERAGE ndash Benefits are available for a broad range of healthcare services including visits to specialists

physical therapy and home health care x CONVENIENCE ndash Usually there are no claim forms to file x Out-of-network services are healthcare services provided by a licensed provider outside Empirersquos PPO network or the

BlueCard PPO networks of other Blue Cross andor Blue Shield plans For most services you can choose in-network or out-of-network However some services are only available in-network When you use out-of-network services You pay an annual deductible and coinsurance plus any amount above the maximum allowed amount (the

maximum Empire will pay for a covered service) This amount is currently 275 of Medicarersquos Fee Schedule (except for physical therapy services which is 200 of Medicarersquos Fee Schedule and Certified Social Worker which is 225 of Medicarersquos Fee Schedule) if you use a BlueCard provider you will pay only the lower of billed charges or a negotiated rate and your member liability

You will usually have to pay the provider when you receive care You will need to file a claim to be reimbursed by Empire

wwwempirebluecom 7

The following chart shows your specific plan information as of July 1 2013 See the Details and Definitions section for explanations of terms in the chart

IN-NETWORK OUT-Of-NETWORK

ANNUAL DEDUCTIBLE $0 $250Individual $750Family

CO-PAYMENT (for office visits and certain covered services)

$15 per visit (Non-Specialist)

$20 per visit (Specialist)

NA

CO-PAYMENT (for hospital inpatient admissions)

$0 NA

CO-PAYMENT (for emergency room) $75 per visit (waived if admitted to hospital within 24 hours)

$75 per visit (waived if admitted to hospital within 24 hours)

COINSURANCE NA You pay 20 of allowed amount Plan pays 80 of maximum allowed amount

ANNUAL OUT-OF-POCKET LIMIT

(includes Deductible Coinsurance Copayments and cost sharing for Prescription drug coverage)

NA $1250Individual $3250Family

LIFETIME MAXIMUM Unlimited Unlimited

COST SHARE CREDIT If on the day before the effective date of this benefit booklet a member was covered under a group major medical or extended medical contract issued to your group by us or another carrier any covered expenses applied to the in-network and out-of-network deductible and in-network and out-of-network out-of-pocket limit incurred by the member under the prior group contract during the same benefit period will be applied to the satisfaction of any in-network and out-of-network deductible and in-network and out-of-network out-of-pocket limit required under this benefit booklet during the same benefit period for such member for that year only This applies only to members who are covered on the initial effective date of the new benefit booklet with us

HOW TO ACCESS PRIMARY AND SPECIALTY CARE SERVICES Your health plan covers certain primary and specialty care services To access primary care services simply visit any network physician who is a general or family practitioner internist or pediatrician Your health plan covers care provided by any network specialty care provider you choose Referrals are never needed to visit any network specialty care provider To make an appointment call your physicianrsquos office

x Tell them you are an Empire member x Have your Member ID card handy They may ask you for your group number member ID number or

office visit copay x Tell them the reason for your visit

When you go for your appointment take your Member ID card

WHEN YOU NEED CARE AFTER NORMAL OFFICE HOURS After hours care is provided by your physician who may have a variety of ways of addressing your needs Call your physician for instructions on how to receive medical care after their normal business hours on weekends and holidays This includes information about how to receive non-Emergency Care and non-Urgent Care within the service area for a condition that is not life threatening but that requires prompt medical attention If you have an emergency call 911 or go to the nearest emergency room

8 wwwempirebluecom

WHERE TO FIND NETWORK PROVIDERS Empirersquos PPO network gives you access to providers within the planrsquos operating area of 28 eastern New York State counties See ldquooperating areardquo in the Details and Definitions section for a listing of counties

To locate a provider in Empirersquos operating area visit wwwempirebluecom You can search for providers by name address language spoken specialty and hospital affiliation The search results include a map and directions to the providerrsquos office Or ask your Benefits Administrator to see Empirersquos PPO Directory

You can also request that a directory be mailed to you free of charge by calling Member Services at 1-855-519-9537 Call 1-800-810-BLUE (2583) or visit wwwbcbscom to locate participating BlueCard PPOreg providers

TRANSITIONAL CARE Networks grow and change and sometimes a provider will move or leave the network that serves your Plan If you are an existing member and the provider with whom you are in an ongoing course of treatment leaves the network Empire will notify you at least 30 calendar days prior to the physicianrsquos termination or within 15 days after we become aware of the providerrsquos change in status You may continue to receive medically necessary covered services from a provider for an ongoing course of treatment for up to 90 days after heshe leaves the network if the provider agrees to (1) reimbursement at the rates applicable prior to start of transitional care (2) to adhere to the planrsquos quality assurance requirements (3) to provide the plan with necessary medical information related to this care and (4) to adhere to the plans policies and procedures After 90 days you must select a new provider Continued care is available to pregnant women who are in the second and third trimester through the delivery and postpartum period You must contact our Medical Management department to arrange this continued care Transitional care will not be approved if the provider leaves the network due to imminent harm to patient care a determination of fraud or a final disciplinary action by a state licensing board (or other governmental agency) that impairs the health care professionalrsquos ability to practice New plan members who are in treatment for a disabling and degenerative or life threatening condition or disease are eligible for up to 60 days of continued care following their initial enrollment date Members who are pregnant and in their second or third trimester on the effective date of coverage may continue care through delivery and the postpartum period The provider must agree to (1) reimbursement at the rates applicable prior to start of transitional care (2) to adhere to the planrsquos quality assurance requirements (3) to provide the plan with necessary medical information related to this care and (4) to adhere to the plans policies and procedures in both situations You must contact our Medical Management department to arrange this continued care

INTER-PLAN PROGRAMS Out-of-Area Services

Empire has a variety of relationships with other Blue Cross andor Blue Shield Licensees referred to generally as ldquoInter-Plan Programsrdquo Whenever you obtain healthcare services outside of Empirersquos service area the claims for these services may be processed through one of these Inter-Plan Programs which include the BlueCard Program and may include negotiated National Account arrangements available between Empire and other Blue Cross and Blue Shield Licensees

Typically when accessing care outside Empirersquos service area you will obtain care from healthcare providers that have a contractual agreement (ie are ldquoparticipating providersrdquo) with the local Blue Cross andor Blue Shield Licensee in that other geographic area (ldquoHost Bluerdquo) In some instances you may obtain care from nonparticipating healthcare providers Empirersquos payment practices in both instances are described below

BlueCardreg Program Under the BlueCardreg Program when you access covered healthcare services within the geographic area served by a Host Blue Empire will remain responsible for fulfilling Empirersquos contractual obligations However the Host Blue is responsible for contracting with and generally handling all interactions with its participating healthcare providers

Whenever you access covered healthcare services outside Empirersquos service area and the claim is processed through the BlueCard Program the amount you pay for covered healthcare services is calculated based on the lower of

x The billed covered charges for your covered services or x The negotiated price that the Host Blue makes available to Empire

Often this ldquonegotiated pricerdquo will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider Sometimes it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements incentive payments andor other credits or charges Occasionally it may

wwwempirebluecom 9

be an average price based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price

Estimated pricing and average pricing going forward also take into account adjustments to correct for over- or underestimation of modifications of past pricing for the types of transaction modifications noted above However such adjustments will not affect the price Empire uses for your claim because they will not be applied retroactively to claims already paid

Laws in a small number of states may require the Host Blue to add a surcharge to your calculation If any state laws mandate other liability calculation methods including a surcharge we would then calculate your liability for any covered healthcare services according to applicable law

Under certain circumstances if Empire pays the healthcare provider amounts that are your responsibility such as Deductibles Copayments or Coinsurance Empire may collect such amounts directly from you You agree that Empire has the right to collect such amounts from you

Non-Participating Healthcare Providers Outside Empirersquos Service Area Your Liability Calculation

When covered healthcare services are provided outside of Empirersquos service area by non-participating healthcare providers the amount you pay for such services will generally be based on either the Host Bluersquos nonparticipating healthcare provider local payment or the pricing arrangements required by applicable state law In these situations you may be liable for the difference between the amount that the non-participating healthcare provider bills and the payment Empire will make for the Covered Services as set forth in this paragraph

Exceptions

In certain situations Empire may use other payment bases such as billed covered charges the payment we would make if the healthcare services had been obtained within our Service Area or a special negotiated payment as permitted under Inter-Plan Programs Policies to determine the amount Empire will pay for services rendered by nonparticipating healthcare providers In these situations you may be liable for the difference between the amount that the non-participating healthcare provider bills and the payment Empire will make for the covered services as set forth in this paragraph

BLUECARDreg PPO PROGRAM Care When you are Out of Our Service Area Within the US

If you are traveling outside the Empire service area the BlueCardreg PPO program lets you use other Blue Cross andor Blue Shield plansrsquo PPO networks of physicians hospitals and other health care providers As a PPO member you are automatically enrolled in the BlueCardreg PPO program This allows you to receive in-network benefits across the country outside of our network area from providers participating with other Blue Plansrsquo PPO networks As long as these services are covered services under your Contract or Certificate they will be treated as in-network services If you are traveling and need medical care call 1-800-810-BLUE (2583) for the names and addresses of the PPO providers nearest you You may also visit the Blue Cross and Blue Shield Association Web site to locate providers in other states at wwwbcbscom BlueCardpound Worldwide Program The BlueCard Worldwide program provides hospital and professional coverage through an international network of healthcare providers With this program yoursquore assured of receiving care from licensed healthcare professionals The program also assures that at least one staff member at the hospital will speak English or the program will provide translation assistance Herersquos how to use BlueCard Worldwide

x Call 1-804-673-1177 24 hours a day seven days a week for the names of participating doctors and hospitals Outside the US you may use this number by dialing an ATampT Directreg1 Access Number

x Show your Empire ID card at the hospital If yoursquore admitted you will only have to pay for expenses not covered by your contract such as co-payments coinsurance deductibles and personal items Remember to call Empire within 24 hours or as soon as reasonably possible

x If you receive outpatient hospital care or care from a doctor in the BlueCard Worldwide Program pay the bill at the time of treatment When you return home submit an international claim form and attach the bill This claim form is available from the healthcare provider or by calling the BlueCard Worldwide Program Mail the claim to the address on the form You will receive reimbursement less any coinsurance amount above the maximum allowed amount

10 wwwempirebluecom

Your Benefits at a Glance

Empirersquos plan provides a broad range of benefits to you and your family Following is a brief overview of your coverage Some services require precertification with Empirersquos Medical Management Program See the Health Management section for details

YOU PAY

HOME OFFICEOUTPATIENT CARE IN-NETWORK OUT-OF-NETWORK

HOMEOFFICE VISITS $15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

ONLINE VISITS $15 Primary co-payment per visit

Deductible and 20 coinsurance

SPECIALIST VISITS $20 co-payment per visit Deductible and 20 coinsurance

CHIROPRACTIC CARE x Up to an annual in-network and out of network maximum of $1000

$15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

SECOND OR THIRD SURGICAL OPINION $10 co-payment per visit Deductible and 20 coinsurance

DIABETES EDUCATION AND MANAGEMENT $10 co-payment per visit Deductible and 20 coinsurance

ALLERGY CARE x Office Visit x Testing x Treatment

$15 per visit (Non-Specialist) $20 per visit (Specialist) $0 $0

Deductible and 20 coinsurance

SURGERY $0 Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

Empirersquos Medical Management Program must be contacted to determine medical necessity of all in-network and out-of-network chiropractic care after

the fifth visit We will not pay for any visits which we determine were not medically necessary in accordance with your contract

wwwempirebluecom 11

YOU PAY

HOME OFFICEOUTPATIENT CARE IN-NETWORK OUT-OF-NETWORK

DIAGNOSTIC PROCEDURES

x X-rays and other imaging x Laboratory tests

$0 $0

Deductible and 20 coinsurance

CHEMOTHERAPY $0 Deductible and 20 coinsurance

HIGH COST DIAGNOSTIC TESTS (ie MRIsMRAs Nuclear cardiology servicesPETCAT scans)

$0 Deductible and 30 coinsurance

RADIATION $0 Deductible and 20 coinsurance

PRE-SURGICAL TESTING $0 Deductible and 20 coinsurance

ANESTHESIA $0 Deductible and 20 coinsurance

KIDNEY DIALYSIS $0 Deductible and 20 coinsurance

SECOND OR THIRD MEDICAL OPINION FOR CANCER DIAGNOSIS

$15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

CARDIAC REHABILITATION $15 per visit (Non-Specialist)

$20 per visit (Specialist) Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

12 wwwempirebluecom

YOU PAY

HOME OFFICEOUTPATIENT CARE IN-NETWORK OUT-OF-NETWORK

ANNUAL PHYSICAL EXAM x One per calendar year

$15 per visit (Non-Specialist)

$20 per visit (Specialist) Not covered

DIAGNOSTIC SCREENING TESTS x Cholesterol 1 every 2 years (except for triglyceride testing) x Diabetes (if pregnant or considering pregnancy) x Colorectal cancer

ndash Fecal occult blood test if age 40 or over 1 per year ndash Sigmoidoscopy if age 40 or over 1 every 2 years

x Routine Prostate Specific Antigen (PSA) in asymptomatic males ndash Over age 50- 1 every year ndash Between ages 40-49 if risk factors exist 1 per year ndash If prior history of prostate cancer PSA at any age ndash Diagnostic PSA 1 per year

$0 $0

$0

$0

Deductible and 20 coinsurance

WELL-WOMAN CARE x Office visits x Pap smears x Bone Density testing and treatment

ndash Ages 55 through 65 - 1 baseline ndash Age 65 and older - 1 every 2 years (if baseline before

age 65 does not indicate osteoporosis) ndash under Age 65 - 1 every 2 years (if baseline before age

65 indicates osteoporosis) x Mammogram (based on age and medical history)

ndash Ages 35 through 39 ndash 1 baseline ndash Age 40 and older ndash 1 per year

x Womenrsquos sterilization procedures and counseling x Breastfeeding support supplies and counseling

ndash One breast pump per pregnancy x Screenings andor counseling for Gestational diabetes

Human Papillomavirus (HPV) sexually transmitted infections STIs) Human immune deficiency (HIV) interpersonal and domestic violence

$15 per visit (Non-Specialist) $20 per visit (Specialist)

$0 $0

$0

$0 $0

$0

Deductible and 20 coinsurance

WELL-CHILD CARE (covered services and the number of visits are based on the prevailing clinical standards of the American Academy of Pediatrics) x In-hospital visits

ndash Newborn 2 in-hospital exams at birth following vaginal delivery

ndash Newborn 4 in-hospital exams at birth following c-section delivery

x Office visits ndash From birth up 1st birthday 7 visits ndash Ages 1 through 4 years of age 6 visits ndash Ages 5 through 11 years of age 7 visits ndash Ages 12 up to 17 years of age 6 visits ndash Ages 18 to 19th birthday 2 visits

x Lab tests x Immunizations (office visits are not required)

$0

$0

$0 $0

$0

$0

Deductible and 20 coinsurance Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements See the Preventive Care section for more details

wwwempirebluecom 13

YOU PAY

EMERGENCY CARE IN-NETWORK OUT-OF-NETWORK

EMERGENCY ROOM $75 per visit co-payment (waived if admitted to the same hospital within 24 hours)

PHYSICIANrsquoS OFFICE $15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

EMERGENCY AIR AMBULANCE x Transportation to nearest acute care hospital for

emergency inpatient admissions

$0

Covered in-network when specified criteria is met subject to any applicable cost sharing You may be required to pay the difference between the maximum allowed amount and the total charges of an out-of-network provider

EMERGENCY LAND AMBULANCE x Local professional ground ambulance to

nearest hospital $0 up to the maximum allowed

amount

Covered in-network subject to meeting emergency criteria When services are delivered by an out-of-network land ambulance provider that is not licensed under the NY Public Health Law you may be required to pay up to the difference between the maximum allowed amount and the providerrsquos total charges13

MATERNITY CARE IN-NETWORK OUT-OF-NETWORK

PRENATAL AND POSTNATAL CARE (In doctorrsquos office) $0 Deductible and 20 coinsurance

LAB TESTS SONOGRAMS AND OTHER DIAGNOSTIC PROCEDURES $0 Deductible and 20 coinsurance

ROUTINE NEWBORN NURSERY CARE (In hospital) $0 Deductible and 20 coinsurance

OBSTETRICAL CARE (In hospital) $0 Deductible and 20 coinsurance

OBSTETRICAL CARE (In birthing center) $0 Not covered

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

13 New York State law prohibits land ambulance providers in New York State from balance-billing beyond reasonable and customary amounts (you will be responsible for in-network cost share such as co-payments deductibles and coinsurance)

14 wwwempirebluecom

YOU PAY

HOSPITAL SERVICES IN-NETWORK OUT-OF-NETWORK

SEMI-PRIVATE ROOM AND BOARD $0 Deductible and 20 coinsurance

ANESTHESIA AND OXYGEN $0 Deductible and 20 coinsurance

CHEMOTHERAPY AND RADIATION THERAPY $0 Deductible and 20 coinsurance

DIAGNOSTIC X-RAYS AND LAB TESTS $0 Deductible and 20 coinsurance

DRUGS AND DRESSINGS $0 Deductible and 20 coinsurance

GENERAL SPECIAL AND CRITICAL NURSING CARE $0 Deductible and 20 coinsurance

INTENSIVE CARE $0 Deductible and 20 coinsurance

KIDNEY DIALYSIS $0 Deductible and 20 coinsurance

SERVICES OF LICENSED PHYSICIANS AND SURGEONS $0 Deductible and 20 coinsurance

SURGERY (Inpatient and Outpatient) $0 Deductible and 20 coinsurance

DURABLE MEDICAL EQUIPMENT AND SUPPLIES IN-NETWORK OUT-OF-NETWORK

DURABLE MEDICAL EQUIPMENT (ie hospital-type bed wheelchair sleep apnea monitor)

$0 Not covered

ORTHOTICS $0 Not covered

PROSTHETICS (ie artificial arms legs eyes ears) $0 Not covered

MEDICAL SUPPLIES (ie catheters oxygen syringes) $0

Difference between the maximum allowed amount and the total charge ( coinsurance does not apply)

NUTRITIONAL SUPPLEMENTS (enteral formulas and modified solid food products)

$0 Deductible and 20 coinsurance

HEARING AIDS (one device per ear every 3 years maximum of $1500 combined in and out-of-network) $0 Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

Does not include inpatient or outpatient behavioral healthcare or physical therapyrehabilitation For a second procedure performed during an authorized surgery through the same incision Empire pays for the procedure with the higher maximum allowed amount For a second procedure done through a separate incision Empire will pay the maximum allowed amount for the procedure with the higher allowance and up to 50 of the maximum allowed amount for the other procedure $0 outside of the United States

wwwempirebluecom 15

YOU PAY

SKILLED NURSING AND HOSPICE CARE IN-NETWORK OUT-OF-NETWORK

SKILLED NURSING FACILITY Up to 120 days per calendar year $0 Not covered

HOSPICE Unlimited days per lifetime $0 Not covered

HOME HEALTH CARE IN-NETWORK OUT-OF-NETWORK

HOME HEALTH CARE

Up to 200 visits per calendar year (a visit equals 4 hours of care)

$0

Deductible and 20 coinsurance only

HOME INFUSION THERAPY $0 Not covered

PHYSICAL OCCUPATIONAL SPEECH OR VISION THERAPY IN-NETWORK OUT-OF-NETWORK

PHYSICAL THERAPY AND REHABILITATION

x Up to 60 days of inpatient service per calendar year

x Up to 60 visits combined in home office or outpatient facility per calendar year

$20 per visit (Specialist)

$15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

Deductible and 20 coinsurance

OCCUPATIONAL AND SPEECH THERAPY

x Up to 60 visits per person combined in home office or outpatient facility per calendar year

$15 per visit (Non-Specialist) $20 per visit (Specialist) Deductible and 20 coinsurance

VISION THERAPY

x Up to 60 visits per person combined in home or office per calendar year

$15 per visit (Non-Specialist) $20 per visit (Specialist) Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

Treatment maximums are combined for in-network and out-of-network care $0 outside of the United States

16 wwwempirebluecom

YOU PAY

MENTAL HEALTH CARE IN-NETWORK OUT-OF-NETWORK

OUTPATIENT x Up to 60 visits per calendar year 1

$25 co-payment Deductible and 20 coinsurance

INPATIENT x Up to 90 days per calendar year 1

x Up to 90 visits from mental health care professionals

per calendar year 1

$0

$0

Deductible and 20 coinsurance

Deductible and 20 coinsurance

ALCOHOL OR SUBSTANCE ABUSE TREATMENT IN-NETWORK OUT-OF-NETWORK

OUTPATIENT x Up to 60 visits per calendar year including up to

20 visits for family counseling $0 Deductible and 20 coinsurance

INPATIENT x Up to 7 days detoxification per calendar year 1 x Up to 30 days rehabilitation per calendar year 1

$0 $0

Deductible and 20 coinsurance

Deductible and 20 coinsurance

PHARMACY (RETAIL AND MAIL SERVICE) IN-NETWORK OUT-OF-NETWORK

RETAIL PHARMACY (34 day supply) x Tier 1 x Tier 2

x Tier 3

x 20 co-payment $5 minimum and up to a maximum of $20 per prescription

x 25 co-payment $5 minimum and up to a maximum of $30 per prescription

x 25 co-payment $5 minimum and up to a maximum of $30 per prescription

x

40 Coinsurance

(within the United States)

20 Coinsurance

(outside the United States)

x

MAIL SERVICE (90 day supply-includes some specific Retail locations)

x $15 co-payment Not covered

Generic and Select Oral Contraceptives and Contraceptive Devices

x $0 cost share Not covered

(All of the prescription drug options listed above meet the Centers for Medicare and Medicaid Services (CMS) standards for Medicare prescription drug coverage and each option is considered Creditable Coverage under the Medicare Modernization Act of 2003)

OTHER SERVICES IN-NETWORK OUT-OF-NETWORK SEX CHANGE SURGERY OR TREATMENT OF GENDER IDENTITY DISORDERS (for hospital inpatient only) x Lifetime Maximum $75000 for transformative surgeries

Lifetime Maximum combined In-network and Out-of-Network

$0 Deductible and 20 coinsurance

Treatment maximums are combined for in-network and out-of-network care

wwwempirebluecom 17

Coverage

Doctorrsquos Services When you need to visit your doctor or a specialist Empire makes it easy In-network you pay only a co-payment There are no claim forms to fill out for X-rays blood tests or other diagnostic procedures ndash as long as they are requested by the doctor and done in the doctorrsquos office or a network facility For in-network allergy office visits you pay only a co-payment In-network allergy testing is covered in full Ongoing in-network allergy treatments are covered in full

When you visit an out-of-network physician or use an out-of-network facility for diagnostic procedures including allergy testing and treatment visits you pay the deductible and coinsurance plus any amount above Empirersquos allowed amount

Tips For Visiting Your Doctor x When you make your appointment confirm that the doctor is an Empire network provider and that heshe is

accepting new patients

x Arrange ahead of time to have pertinent medical records and test results sent to the doctor

x If the doctor sends you to an outside lab or radiologist for tests or X-rays call Member Services to confirm that the supplier is in Empirersquos network This will ensure that you receive maximum benefits

Ask about a second opinion anytime that you are unsure about surgery or a cancer diagnosis The specialist who provides the second or third opinion cannot perform the surgery To confirm a cancer diagnosis or course of treatment second or third opinions are paid at the in-network level even if you use an out-of-network specialist as long as your participating doctor provides a written referral to a non-participating specialist If you visit a non-participating specialist without a written referral you must pay the out-of-network deductible and coinsurance

WOMENrsquoS HEALTH AND CANCER RIGHTS OF ACT 1998

This federal law applies to almost all health care plans except Medicare Supplement and Medicare Risk plans as of plan years beginning on or after October 21 1998 The law imposes certain requirements on employee benefit plans and health insurers that provide medical and surgical benefits with respect to a mastectomy Specifically in the case of a participant or beneficiary who receives benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy the law requires coverage for

x Reconstruction of the breast on which the mastectomy has been performed x Surgery and reconstruction of the other breast to produce a symmetrical appearance x Prostheses and treatment of physical complications at all stages of mastectomy including lymphedemas

The coverage described above shall be provided in a manner determined in consultation with the attending physician and the patient This coverage is subject to all coverage terms and limitations (for example Deductibles and Coinsurance) consistent with those established for other benefits under the plan

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Consultation requested by the attending physician for advice on an illness or injury

This includes the Specialist e-Consultations Program If Your Participating Provider is in Our Cooperative Care program and is rendering primary care services to You he or she may request an electronic consultation with a Specialist to help evaluate Your condition or diagnosis The electronic consultation will be provided by a Participating Provider who has agreed to participate in Our ldquoeconsultationrdquo program and will be selected by Your Participating Provider in his or her clinical judgement The electronic consultation will be at no cost to You Your Participating Provider may consider the information provided by the Specialist in determining Your treatment The consultation will be conducted using electronic information and communication technologies such as secure web-based email fax andor exchange of electronic medical records The results may be documented in an electronic health record

x Diabetes supplies prescribed by an authorized provider Blood glucose monitors including monitors for the legally blind

18 wwwempirebluecom

Testing strips Insulin syringes injection aids cartridges for the legally blind insulin pumps and appurtenances and insulin

infusion devices Oral agents for controlling blood sugar Other equipment and supplies required by the New York State Health Department Data management systems

x Diabetes self-management education and diet information including

Education by a physician certified nurse practitioner or member of their staff frac34 At the time of diagnosis frac34 When the patientrsquos condition changes significantly frac34 When medically necessary

Education by a certified diabetes nurse educator certified nutritionist certified dietitian or registered dietitian when referred by a physician or certified nurse practitioner This benefit may be limited to a group setting when appropriate

Home visits for education when medically necessary

x Diagnosis and treatment of degenerative joint disease related to temporomandibular joint (TMJ) syndrome that is not a dental condition

x Diagnosis and treatment for Orthognathic surgery that is not a dental condition

x Medically necessary hearing examinations

x Foot care and orthotics associated with disease affecting the lower limbs such as severe diabetes which requires care from a podiatrist or physician

x Gender Reassignment Surgery and related non-cosmetic services

Lifetime Maximum benefit of $75000 for transgender surgery Counseling Services are covered These services will not count toward the $75000 Lifetime Maximum Benefit

x Cosmetic Services received in association with gender transformation are NOT covered including

x Reduction Thyroid Chondroplasty x Liposuction x Rhinoplasty x Facial Bone Reconstruction x Face Lift x Blepharoplasty x Voice Modification Surgery x Hair Removalhairplasty x Breast Augmentation

ONLINE VISITS

Your coverage includes online physician office visits Covered Services include a medical consultation using the internet via a webcam with online chat or voice functions Services are provided by board certified licensed primary care physicians Online visits are not for specialist care Common types of diagnoses and conditions treated online are cough fever headaches sore throat routine child health issues influenza upper respiratory infections sinusitis bronchitis and urinary tract infections when uncomplicated in nature Online visits are not meant for the following purposes

To get reports of normal lab or other test results To request an office appointment To ask billing insurance coverage or payment questions To ask for a referral to a specialist Doctor To request precertification for a benefit under your health Plan or To ask the physician to consult with another physician

You must have the following computer hardware in order for the online website to work properly USB or built in webcam (to enable two-way video during web conversations) and audio functionality To minimize audio feedback use a headset or headphones with a built-in microphone To begin the online visit log on to wwwlivehealthonlinecom and establish an

wwwempirebluecom 19

online account by providing some basic information about you and your insurance plan Before you connect to a Doctor you will be asked the kind of condition you want to discuss with the Doctor list your local pharmacy provide information for the credit card you want your cost share for the visit to be billed to agree to the terms of use and select an available physician If you are not in New York State when you seek an online visit you will need to check to be sure an online Doctor is available in the state you are in because online Doctors are not available in every state The visit with the physician will not start until you provide the above information and click ldquoconnectrdquo The visit will be documented in an electronic health record You may access your records and print them and may email or fax them to your primary care physician

CLINICAL TRIALS We Cover the routine patient costs for Your participation in an approved clinical trial and such coverage shall not be subject to Utilization Review if You are

x Eligible to participate in an approved clinical trial to treat either cancer or other life-threatening disease or condition and

x Referred by a Participating Provider who has concluded that Your participation in the approved clinical trial would be appropriate

All other clinical trials including when You do not have cancer or other life-threatening disease or condition may be subject to the Utilization Review and External Appeal sections of this booklet We do not Cover the costs of the investigational drugs or devices the costs of non-health services required for You to receive the treatment the costs of managing the research or costs that would not be covered under this benefit plan for non-investigational treatments provided in the clinical trial An ldquoapproved clinical trialrdquo means a phase I II III or IV clinical trial that is

x A federally funded or approved trial x Conducted under an investigational drug application reviewed by the federal Food and Drug Administration or x A drug trial that is exempt from having to make an investigational new drug application

Whatrsquos Not Covered The following medical services are not covered

x Routine foot care including care of corns bunions calluses toenails flat feet fallen arches weak feet and chronic foot strain

x Symptomatic complaints of the feet except capsular or bone surgery related to bunions and hammertoes x Orthotics for treatment of routine foot care x Routine hearing exams x Services such as laboratory X-ray and imaging and pharmacy services as required by law from a facility in which

the referring physician or hisher immediate family member has a financial interest or relationship x Services given by an unlicensed provider or performed outside the scope of the providerrsquos license

20 wwwempirebluecom

Emergency Care IF YOU NEED EMERGENCY CARE

Should you need emergency care your plan is there to cover you Emergency care is covered in the hospital emergency room

To be covered as emergency care the condition must be a medical or behavioral condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in

1 Placing the health of the person afflicted with such condition (or with respect to a pregnant woman the health of the woman or her unborn child) in serious jeopardy or in the case of a behavioral condition placing the health of such person or others in serious jeopardy

2 Serious impairment to such personrsquos bodily functions 3 Serious dysfunction of any bodily organ or part of such person or

4 Serious disfigurement of such person

Emergency Services are defined as a medical screening examination that is within the capability of the emergency department of a Hospital including ancillary services routinely available to the emergency department to evaluate an Emergency Condition and within the capabilities of the staff and facilities available at the Hospital such further medical examination and treatment as are required to stabilize the patient With respect to an emergency medical condition the term ldquoStabilizerdquo means to provide such medical treatment of the condition as may be necessary to assure within reasonable medical probability that no material deterioration of the condition is likely to result from or occur during the transfer of the patient from a facility or to deliver a newborn child (including the placenta)

Emergency Services are not subject to prior authorization requirements

Emergency Assistance 911 In an emergency call 911 for an ambulance or go directly to the nearest emergency room If possible go to the emergency room of a hospital in Empirersquos PPO network or the PPO network of another Blue Cross andor Blue Shield plan

You pay only a co-payment for a visit to an emergency room This co-payment is waived if you are admitted to the hospital within 24 hours If you make an emergency visit to your doctorrsquos office you pay the same co-payment as for an office visit

Benefits for treatment in a hospital emergency room are limited to the initial visit for an emergency condition A participating provider must provide all follow-up care in order to receive maximum benefits Remember You will need to show your Empire BlueCross BlueShield ID card when you arrive at the emergency room

Tips For Getting Emergency Care x If time permits speak to your physician to direct you to the best place for treatment x If you have an emergency while outside Empirersquos service area anywhere in the United States follow the same steps

described on the previous page If the hospital participates with another Blue Cross andor Blue Shield plan in the BlueCardpound PPO program your claim will be processed by the local plan Be sure to show your Empire ID card at the emergency room If the hospital does not participate in the BlueCard PPO program you will need to file a claim

x If you have an emergency outside of the United States and visit a hospital which participates in the BlueCardpound

Worldwide program simply show your Empire ID card The hospital will submit their bill through the BlueCard Worldwide Program If the hospital does not participate with the BlueCard Worldwide program you will need to file a claim

Please refer to the Health Management section for details regarding precertification requirements

wwwempirebluecom 21

Whatrsquos Not Covered These emergency services are not covered

x Use of the Emergency Room To treat routine ailments Because you have no regular physician Because it is late at night (and the need for treatment is not sudden and serious)

Emergency Air Ambulance We will provide in-network coverage for air ambulance services when needed to transport you to the nearest acute care hospital in connection with an emergency room or emergency inpatient admission or emergency outpatient care subject to cost sharing obligations when the following conditions are met

x Your medical condition requires immediate and rapid ambulance transportation and services cannot be provided by land ambulance due to great distances and the use of land transportation would pose an immediate threat to your health

x Services are covered to transport you from one acute care hospital to another only if the transferring hospital does not have adequate facilities to provide the medically necessary services needed for your treatment as determined by Empire and use of land ambulance would pose an immediate threat to your health

If Empire determines that the condition for coverage for air ambulance services has not been met but your condition did require transportation by land ambulance to the nearest acute care hospital Empire will only pay up to the maximum allowed amount that would be paid for land ambulance to that hospital You may be required to pay the difference between the maximum allowed amount and the total charges of an out-of-network provider

Please refer to the Health Management section for details regarding precertification requirements

Emergency Land Ambulance We will provide coverage for land ambulance transportation to the nearest acute care hospital in connection with emergency room care or emergency inpatient admission provided by an ambulance service when a prudent layperson possessing an average knowledge of medicine and health could reasonably expect the absence of such transportation to result in

x placing the memberrsquos health afflicted with a condition in serious jeopardy or for behavioral condition place the health of a member or others in serious jeopardy or

x serious impairment to a personrsquos bodily functions x serious dysfunction of any bodily organ or part of a person or x serious disfigurement to the member

Non-Emergency Ambulance Transportation

We cover non-emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance as appropriate) between facilities when the transport is any of the following

x From a non-participating Hospital to a participating Hospital x To a Hospital that provides a higher level of care that was not available at the original Hospital x To a more cost-effective Acute care Facility or x From an Acute Facility to a sub-Acute setting LimitationsTerms of Coverage

x We do not cover travel or transportation expenses unless connected to an Emergency Condition or due to a Facility transfer approved by us even though prescribed by a Physician

x We do not cover non-ambulance transportation such as ambulette van or taxi cab x Coverage for air ambulance related to an Emergency Condition or air ambulance related to non-emergency

transportation is provided when your medical condition is such that transportation by land ambulance is not appropriate and your medical condition requires immediate and rapid ambulance transportation that cannot be provided by land ambulance and one of the following is met The point of pick-up is inaccessible by land vehicle or Great distances or other obstacles (for example heavy traffic) prevent your timely transfer to the nearest Hospital

with appropriate facilities

22 wwwempirebluecom

Maternity Care IF YOU ARE HAVING A BABY

There are no out-of-pocket expenses for maternity and newborn care when you use in-network providers That means you do not need to pay a co-payment when you visit the obstetrician Furthermore routine tests related to pregnancy obstetrical care in the hospital or birthing center as well as routine newborn nursery care are all covered 100 in-network

For out-of-network maternity services you pay the deductible coinsurance and any amount above the maximum allowed amount Empirersquos reimbursements for the remaining balance may be consolidated in up to three installments as follows

x Two payments for prenatal care x One payment for delivery and post-natal care

Please refer to the Health Management section for details regarding precertification requirements Obstetrical care in the hospital or an in-network birthing center is covered up to 48 hours after a normal vaginal birth and 96 hours after a Cesarean section

NEWBORNSrsquo AND MOTHERSrsquo HEALTH PROTECTION ACT OF 1996 Group health plans and health insurance issuers generally may not under Federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section However Federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under Federal law require that a provider obtain authorization from the Program or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours as applicable) Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x One home care visit if the mother leaves earlier than the 48-hour (or 96-hour) limit The mother must request the visit from the hospital or a home health care agency within this timeframe (precertification is not required) The visit will take place within 24 hours after either the discharge or the time of the request whichever is later

x Services of a certified nurse-midwife affiliated with a licensed facility The nurse-midwifersquos services must be provided under the direction of a physician

x Parent education and assistance and training in breast or bottle feeding if available x Circumcision of newborn males x Special care for the baby if the baby stays in the hospital longer than the mother Call Empirersquos Medical Management

Program to precertify the hospital stay x Semi-private room

Whatrsquos Not Covered These maternity care services are not covered

x Days in hospital that are not medically necessary (beyond the 48-hour96-hour limits) x Services that are not medically necessary x Private room x Out-of-network birthing center facilities x Private duty nursing

REMEMBER Use a network obstetriciangynecologist to receive the lowest cost maternity care

wwwempirebluecom 23

Hospital Services IF YOU VISIT THE HOSPITAL

Your plan covers most of the cost of your medically necessary care when you stay at a network hospital for surgery or treatment of illness or injury When you use an out-of-network hospital or facility you pay the deductible and coinsurance plus any amount above Empirersquos maximum allowed amount

You are also covered for same-day (outpatient or ambulatory) hospital services such as chemotherapy radiation therapy cardiac rehabilitation and kidney dialysis Same-day surgical services or invasive diagnostic procedures are covered when they

x Are performed in a same-day or hospital outpatient surgical facility x Require the use of both surgical operating and postoperative recovery rooms x May require either local or general anesthesia x Do not require inpatient hospital admission because it is not appropriate or medically necessary and x Would justify an inpatient hospital admission in the absence of a same-day surgery program

Please refer to the Health Management section for details regarding precertification requirements

Tip For Getting Hospital Care x If you are having same-day surgery often the hospital or outpatient facility requires that someone meet you after the

surgery to take you home Ask about their policy and make arrangements for transportation before you go in for surgery

Inpatient And Outpatient Hospital Care

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations for both inpatient and outpatient (same-day) care

x Diagnostic X-rays and lab tests and other diagnostic tests such as EKGs EEGs or endoscopies x Oxygen and other inhalation therapeutic services and supplies and anesthesia (including equipment for administration x Anesthesiologist including one consultation before surgery and services during and after surgery x Blood and blood derivatives for emergency care same-day surgery or medically necessary conditions such as

treatment for hemophilia x MRIsMRAs PETCAT scans and nuclear cardiology services

Please refer to the Health Management section for details regarding precertification requirements

Inpatient Hospital Care

Whatrsquos Covered Following are additional covered services for inpatient care

x Semi-private room and board when The patient is under the care of a physician and A hospital stay is medically necessary

x Coverage is for unlimited days unless otherwise specified x Operating and recovery rooms x Special diet and nutritional services while in the hospital x Cardiac care unit x Services of a licensed physician or surgeon employed by the hospital x Care related to surgery x Breast cancer surgery (lumpectomy mastectomy) including

Reconstruction following surgery Surgery on the other breast to produce a

symmetrical appearance

Prostheses Treatment of physical complications at any stage of a

mastectomy including lymphedemas The patient has the right to decide in consultation with the physician the length of hospital stay following mastectomy surgery

x Use of cardiographic equipment x Drugs dressings and other medically necessary supplies x Social psychological and pastoral services x Reconstructive surgery associated with injuries unrelated to cosmetic surgery x Reconstructive surgery for a functional defect which is present from birth x Physical occupational speech and vision therapy including facilities services supplies and equipment x Facilities services supplies and equipment related to medically necessary medical care x Residential treatment services are not covered

Please refer to the Health Management section for details regarding precertification requirements

24 wwwempirebluecom

Outpatient Hospital Care

Whatrsquos Covered Following are additional covered services for same-day care

x Same-day and hospital outpatient surgical facilities x Surgeons x Surgical assistant if

None is available in the hospital or facility where the surgery is performed and The surgical assistant is not a hospital employee

x Chemotherapy and radiation therapy including medications in a hospital outpatient department doctorrsquos office or facility Medications that are part of outpatient hospital treatment are covered if they are prescribed by the hospital and filled by the hospital pharmacy

x Kidney dialysis treatment (including hemodialysis and peritoneal dialysis) is covered in the following settings until the patient becomes eligible for end-stage renal disease dialysis benefits under Medicare At home when provided supervised and arranged by a physician and the patient has registered with an approved

kidney disease treatment center (professional assistance to perform dialysis and any furniture electrical plumbing or other fixtures needed in the home to permit home dialysis treatment are not covered

In a hospital-based or free-standing facility See ldquohospitalfacilityrdquo in the Definitions section

Please refer to the Health Management section for details regarding precertification requirements

Inpatient Hospital Care

Whatrsquos Not Covered These inpatient services are not covered

x Private duty nursing x Private room If you use a private room you need to pay the difference between the cost for the private room and the

hospitalrsquos average charge for a semiprivate room The additional cost cannot be applied to your deductible or coinsurance

x Diagnostic inpatient stays unless connected with specific symptoms that if not treated on an inpatient basis could result in serious bodily harm or risk to life

x Services performed in the following Nursing or convalescent homes Institutions primarily for rest or for the aged Rehabilitation facilities (except for physical therapy)

Spas Sanitariums Infirmaries at schools colleges or camps

x Any part of a hospital stay that is primarily custodial x Elective cosmetic surgery or any related complications x Hospital services received in clinic settings that do not meet Empirersquos definition of a hospital or other covered facility

See ldquohospitalfacilityrdquo in the Details and Definitions section

Outpatient Hospital Care

Whatrsquos Not Covered These outpatient services are not covered

x Same-day surgery not precertified as medically necessary by Empirersquos Medical Management Program x Routine medical care including but not limited to

Inoculation or vaccination Drug administration or injection excluding chemotherapy

x Collection or storage of your own blood blood products semen or bone marrow

wwwempirebluecom 25

Durable Medical Equipment and Supplies IF YOU NEED EQUIPMENT OR MEDICAL SUPPLIES

Your plan covers the cost of medically necessary prosthetics orthotics and durable medical equipment from network suppliers only In-network benefits and plan maximums are shown in Your Benefits at a Glance section Out-of-network benefits are not available

Please refer to the Health Management section for details regarding precertification requirements

An Empire network supplier may not bill you for covered services If you receive a bill from one of these providers contact Member Services at 1-855-519-9537

Disposable medical supplies such as syringes are covered up to the maximum allowed amount whether you obtain them in- or out-of-network

Coverage for enteral formulas or other dietary supplements for certain severe conditions is available both in- and out-of network If you have prescription drug coverage with Empirersquos pharmacy program you may order these formulas or supplements through Empirersquos pharmacy program Whatrsquos Covered Covered services are listed in Your Benefits At A Glance section Following are additional covered services and limitations

x Prosthetics orthotics and durable medical equipment from network suppliers when prescribed by a doctor including Artificial arms legs eyes ears nose larynx and external breast prostheses Prescription lenses if organic lens is lacking Supportive devices essential to the use of an artificial limb Corrective braces Wheelchairs hospital-type beds oxygen equipment sleep apnea monitors

x Rental (or purchase when more economical) of medically necessary durable medical equipment x Replacement of covered medical equipment because of wear damage or change in patientrsquos need when ordered by a

physician x Reasonable cost of repairs and maintenance for covered medical equipment x Enteral formulas with a written order from a physician or other licensed health care provider The order must

state that The formula is medically necessary and effective and Without the formula the patient would become malnourished suffer from serious physical disorders or die

x Modified solid food products for the treatment of certain inherited diseases A physician or other licensed healthcare provider must provide a written order

x Hearing aids and the examination for their fitting Please refer to the Health Management section for details regarding precertification requirements

Whatrsquos Not Covered The following equipment is not covered x Air conditioners or purifiers x Humidifiers or dehumidifiers x Exercise equipment

x Swimming pools x False teeth

26 wwwempirebluecom

Skilled Nursing and Hospice Care IF YOU NEED SKILLED NURSING OR HOSPICE CARE

You receive coverage through Empirersquos PPO for inpatient care in a skilled nursing facility or hospice Benefits are available for network facilities only Benefits and plan maximums are shown in Your Benefits at a Glance section

Please refer to the Health Management section for details regarding precertification requirements

Skilled Nursing Care

Whatrsquos Covered You are covered for inpatient care in a network skilled nursing facility if you need medical care nursing care or rehabilitation services The number of covered days is listed in Your Benefits at a Glance section Prior hospitalization is not required in order to be eligible for benefits Services are covered if

x The doctor provides A referral and written treatment plan A projected length of stay

An explanation of the services the patient needs and The intended benefits of care

x Care is under the direct supervision of a physician registered nurse (RN) physical therapist or other healthcare professional

Whatrsquos Not Covered The following skilled nursing care services are not covered

x Skilled nursing facility care that primarily Gives assistance with daily living activities Is for rest or for the aged Treats drug addiction or alcoholism

Convalescent care Sanitarium-type care Rest cures

Hospice Care Empire covers unlimited days of hospice care once in a covered personrsquos lifetime Hospices provide medical and supportive care to patients who have been certified by their physician as having a life expectancy of twelve (12) months or less Hospice care can be provided in a hospice in the hospice area of a network hospital or at home as long as it is provided by a network hospice agency

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Hospice care services including Up to 12 hours of intermittent care each day by a registered nurse (RN) or licensed practical nurse (LPN) Medical care given by the hospice doctor Drugs and medications prescribed by the patientrsquos doctor that are not experimental and are approved for use by

the most recent Physiciansrsquo Desk Reference Physical occupational speech and respiratory therapy when required for control of symptoms Laboratory tests X-rays chemotherapy and radiation therapy Social and counseling services for the patientrsquos family including bereavement counseling visits until one year

after death Transportation between home and hospital or hospice when medically necessary Medical supplies and rental of durable medical equipment Up to 14 hours of respite care in any week

Tips for Receiving Skilled Nursing and Hospice Care x To learn more about a skilled nursing facility ask your doctor or caseworker to see the Health Facilities directory x For hospice care in your home ask whether the same caregiver will come each day or whether you will see someone

new each time What recourse do you have if you are not comfortable with the caregiver

wwwempirebluecom 27

Home Health Care IF YOU NEED HOME HEALTH CARE

Home health care can be an alternative to an extended stay in a hospital or a stay in a skilled nursing facility You receive coverage when you use an in-network provider For out-of-network home health care you pay coinsurance only (the deductible does not apply) Out-of-network agencies must be certified by New York State or have comparable certification from another state Benefits and plan maximums are shown in Your Benefits at a Glance section

Home infusion therapy a service sometimes provided during home health care visits is only available in-network An Empire network home health care agency or home infusion supplier cannot bill you for covered services If you receive a bill from one of these providers contact Member Services at 1-855-519-9537 Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Up to 200 home health care visits per year combined in- and out-of-network A visit is defined as up to four hours of care Care can be given for up to 12 hours a day (three visits) Your physician must certify home health care as medically necessary and approve a written treatment plan

x Home health care services include Part-time services by a registered nurse (RN) or licensed practical nurse (LPN) Part-time home health aide services (skilled nursing care) Physical speech or occupational therapy if restorative Medications medical equipment and supplies prescribed by a doctor Laboratory tests

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Up to 200 home health care visits per year combined in- and out-of-network A visit is defined as up to four hours of care Care can be given for up to 12 hours a day (three visits) Your physician must certify home health care as medically necessary and approve a written treatment plan

x Home health care services include Part-time services by a registered nurse (RN) or licensed practical nurse (LPN) Part-time home health aide services (skilled nursing care) Physical speech or occupational therapy if restorative Medications medical equipment and supplies prescribed by a doctor Laboratory tests

Whatrsquos Not Covered The following home health care services are not covered

x Custodial services including bathing feeding changing or other services that do not require skilled care x Out-of-network home infusion therapy

28 wwwempirebluecom

Physical Occupational Speech or Vision Therapy IF YOU NEED THERAPY

You receive benefits through Empirersquos plan for physical occupational speech and vision therapy Outpatient physical occupational speech and vision therapy services are available in-network and out-of-network Inpatient physical therapy can be in-network or out-of-network

Please refer to the Health Management section for details regarding precertification requirements

Tip for Receiving Therapy x Ask for exercises you can do at home that will help you get better faster

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Physical therapy physical medicine or rehabilitation services or any combination of these on an inpatient or outpatient basis up to the plan maximums if Prescribed by a physician Designed to improve or restore physical functioning within a reasonable period of time and Approved by Empirersquos Medical Management Program (for in-network physical therapy only) Designed to improve or restore physical functioning within a reasonable period of time

Outpatient care must be given at home in a therapistrsquos office or in an outpatient facility by an in-network provider inpatient therapy must be short-term

x Occupational speech or vision therapy or any combination of these on an outpatient basis up to the plan maximums if Prescribed by a physician or in conjunction with a physicianrsquos services Given by skilled medical personnel at home in a therapistrsquos office or in an outpatient facility Performed by a licensed speechlanguage pathologist or audiologist

Whatrsquos Not Covered The following therapy services are not covered

x Therapy to maintain or prevent deterioration of the patientrsquos current physical abilities x Tests evaluations or diagnoses received within the 12 months prior to the doctorrsquos referral or order for occupational

speech or vision therapy

wwwempirebluecom 29

Behavioral Healthcare IF YOU NEED BEHAVIORAL HEALTHCARE

At Empire we realize that your mental health is as important as your physical health Thatrsquos why we include behavioral healthcare benefits at little out-of-pocket cost Your behavioral healthcare benefits cover outpatient treatment for alcohol or substance abuse both in-network and out-of-network and inpatient detoxification in-network and out-of-network Inpatient alcohol and substance abuse rehabilitation in a facility is covered in-network and out-of-network Mental healthcare is covered on an inpatient basis in-network and out-of-network and on an outpatient basis in-network and out-of-network

Please note that with the exception of outpatient alcohol and substance abuse treatment the coinsurance that you pay for out-of-network behavioral healthcare services will not count toward reaching your annual out-of-pocket limit

Please refer to the Health Management section for details regarding precertification requirements

Mental Health Care

Whatrsquos Covered In addition to the services listed in Your Benefits at a Glance section the following mental health care service is covered

x Electroconvulsive therapy for treatment of mental or behavioral disorders if precertified by Behavioral Healthcare Management

x Care from psychiatrists psychologists nurse practitioners or licensed clinical social workers providing psychiatric or psychological services within the scope of their practice including the diagnosis and treatment of mental and behavioral disorders Social workers must be licensed by the New York State Education Department or a comparable organization in another state and have three years of post-degree supervised experience in psychotherapy and an additional three years of post-licensure supervised experience in psychotherapy

x Treatment in a New York State Health Department-designated Comprehensive Care Center for Eating Disorders pursuant to Article 27-J of the New York State Public Health Law

x We Cover inpatient mental health care services relating to the diagnosis and treatment of mental nervous and emotional disorders received at Facilities that provide room and board charges

Whatrsquos Not Covered The following mental health care services are not covered

x Care that is not medically necessary x Out-of-network inpatient mental health care at a facility that is not an acute care general hospital x Residential treatment services

Treatment for Alcohol or Substance Abuse

Whatrsquos Covered In addition to the services listed in Your Benefits at a Glance section the following services are covered

x Family counseling services at an outpatient treatment facility These can take place before the patientrsquos treatment begins Any family member covered by the plan may receive one counseling visit per day

x Visits for family counseling are deducted from the 60 visits available for outpatient treatment x Out-of-network outpatient treatment at a facility that

Has New York State certification from the Office of Alcoholism and Substance Abuse Services Is approved by the Joint Commission on the Accreditation of Health Care Organizations if out of state The

program must offer services appropriate to the patientrsquos diagnosis

Whatrsquos Not Covered The following alcohol and substance abuse treatment services are not covered

x Out-of-network outpatient alcohol or substance abuse treatment at a facility that does not meet Empirersquos certification requirements as stated above

x Care that is not medically necessary x Out-of-network inpatient alcohol or substance abuse rehabilitation at a facility that is not an acute care general

hospital x Out-of-network inpatient detoxification at a facility that is not an acute care general hospital x Residential treatment services

30 wwwempirebluecom

Empirersquos Pharmacy Program YOUR PHARMACY BENEFITS PROGRAM

Empire understands that filling prescriptions can be costly To help reduce your costs Empire offers the pharmacy program Your Empire pharmacy program covers most drugs as long as they have been prescribed by a physician and approved by the Federal Drug Administration (FDA) You can choose whether to fill your prescription at a network pharmacy or through the mail order program

FILLING A PRESCRIPTION When you have a prescription filled you must pay the pharmacy the cost share amount for each separate prescription or refill We will pay the pharmacy directly for the remainder of the cost of the prescription or refill The Maximum Allowed Amount for covered Prescription Drugs is the amount determined by us using prescription drug cost information provided by the Pharmacy Benefits Manager (PBM) The amount of the cost share for your prescription drug coverage is listed in Your Benefits At A Glance chart

EMPIRErsquoS DRUG FORMULARY Empire uses a preferred drug formulary which is a list of generic and preferred brand drugs that is distributed to participating pharmacies and providers and is subject to periodic review and modification by Us Your doctor is encouraged to prescribe generic-equivalent drugs as appropriate when possible and to prescribe drugs from the preferred drug formulary when prescribing brand-name drugs

The Preferred Formulary has three tiers

Tier 1 drugs generally have the lowest Cost Share This tier contains preferred medications that are generic single source brand drugs or multi-source brand drugs Tier 2 drugs generally have a higher Cost Share than those in Tier 1 This tier contains preferred medications that are generic single source brand drugs or multi-source brand drugs Tier 3 drugs generally have a higher Cost Share than those on Tier 2 This tier contains non-preferred medications that are generic single source brand drugs or multi-source brand drugs

Preferred Generics For most Prescription Drugs You pay only the Cost-Sharing in the Your Benefits at a Glance section of the booklet An additional charge called an ldquoancillary chargerdquo may apply to some Prescription Drugs when a Prescription Drug on a higher tier is dispensed at You or Your Providerrsquos request and Our formulary includes a chemically equivalent Prescription Drug is available on a lower tier You will have to pay the difference between the full cost of the Prescription Drug on the higher tier and the cost of the Prescription Drug on the lower tier The cost difference is not Covered and must be paid by You in addition to the lower tier Cost-Sharing Your Cost-Sharing will never exceed the Usual and Customary Charge of the Prescription Drug Note Prescription Drugs will always be dispensed as ordered by your Doctor You may ask for or your Doctor may order the Brand Name Drug However if a Generic Drug is available you will have to pay the difference in the cost between the Generic and Brand Name Drug as well as your Tier 1 Copayment Coinsurance By law Generic and Brand Name Drugs must meet the same standards for safety strength and effectiveness Using generics generally saves money yet gives the same quality For certain higher cost generic drugs we reserve the right in our sole discretion to make an exception and not require you to pay the difference in cost between the Generic and Brand Name Drug

wwwempirebluecom 31

You are responsible for paying the full cost (the amount the pharmacy charges You) for any non-Covered Prescription Drug and Our contracted rates (Our Prescription Drug Cost) will not be available to You Tier Assignment Process Empirersquos Pharmacy and Therapeutics (PampT) Committee consists of health care professionals including nurses pharmacists and physicians The purpose of this committee is to assist in determining clinical appropriateness of drugs determining the tier assignments of drugs and advising on programs designed to help improve delivery of care Such programs may include drug utilization programs prior authorization criteria therapeutic conversion programs and drug profiling initiatives The determination of tiers is made based upon clinical decisions provided by the PampT Committee and where appropriate the cost of the Drug relative to other Drugs in its therapeutic class or used to treat the same or similar condition the availability of over-the-counter alternatives and where appropriate certain clinical economic factors Empire retains the right to determine coverage for dosage formulations in terms of covered dosage administration methods (for example by mouth injections topical or inhaled) and may cover one form of administration and exclude or place other forms of administration on another Tier The formulary and procedures are made available to all network providers at least once a year or sooner if there are changes

SPECIALTY DRUGS You or your Physician are required to order your Specialty Drugs directly from a Network Specialty Pharmacy ldquoSpecialty Drugsrdquo are prescription drugs which

x Are approved to treat limited patient populations indications or conditions x Are normally injected infused or require close monitoring by a physician or clinically trained individual or x Have limited availability special dispensing and delivery requirements andor require additional patient support any

or all of which make the drug difficult to obtain through traditional pharmacies

Network Specialty Pharmacies may fill both retail and mail service Specialty Drug prescription orders up to a thirty (30) day supply for retail and mail service and subject to the applicable Deductible Coinsurance or Copayment shown in the Your Benefits At A Glance chart

Network Specialty Pharmacies have dedicated patient care coordinators to help you obtain prior authorization if applicable manage your condition and offer toll-free twenty-four hour access to nurses and registered pharmacists to answer questions regarding your medications

You may obtain a list of the Network Specialty Pharmacies and covered Specialty Drugs by calling the Customer Service telephone number on the back of your ID card or review the lists on our website at wwwempirebluecom select ldquoPharmacyrdquo under the ldquoPlans and Benefitsrdquo tab of the ldquoMember Homerdquo page

In addition certain drugs that must be administered by a physician or other authorized practitioner are required to be ordered from our Network Specialty Pharmacy in order to be covered as a medical benefit If you require one of these drugs your physician or other treating practitioner will order the drug from the required pharmacy You will not be required to fill a prescription for this category of drug

SPECIAL PROGRAMS From time to time we may initiate various programs to encourage Covered Persons to utilize more cost-effective or clinically-effective drugs including but not limited to generic drugs mail order drugs over the counter (OTC) or preferred products Such programs may involve reducing or waiving Copayments or Coinsurance for certain drugs or preferred products for a limited period of time

REMEMBER Benefits are only available for prescriptions filled at network pharmacies or through Empirersquos mail order

NETWORK PHARMACY You must fill a prescription at an Empire network pharmacy for up to a 34-day supply of FDA-approved drugs if prescribed by a physician or other licensed provider Empirersquos pharmacy program offers

x Low cost You can receive up to a 34-day supply for each drug for a single co-payment x Convenience You must present your Empire ID card to the pharmacist along with your prescription Thatrsquos all you

need to get the cost advantages of this program x No claim forms Under your policy guidelines paper claims cannot be submitted The pharmacist must submit your

claim when you fill the prescription

32 wwwempirebluecom

Tip for Using a Network Pharmacy To locate a network pharmacy check the list of national chain pharmacies you received with your ID card For information about network pharmacies that are not a part of a national chain log on to wwwempirebluecom and click on the Rx icon on your home page or call Empirersquos pharmacy program at 1-800-342-9816 You can also call when you are away from home for the name and location of the nearest participating pharmacy

REMEMBER A pharmacist is not required to fill a prescription that in the pharmacistrsquos professional judgment should not be filled

SAVE MONEY WITH EMPIRErsquoS MAIL ORDER PRESCRIPTIONS Certain Prescription Drugs may be ordered through our mail order pharmacy You can reduce your drug co-payments by using Empirersquos pharmacy mail order because you can receive up to a 90-day (three-month) supply of your medication on a single prescription for only one co-payment This service is ideal for members who take the same medication on an on-going basis The same prescriptions filled at a participating pharmacy cost three co-payments for a three-month supply of medicationmdashone co-payment for each 34-day supply In addition Empire waives drug deductibles when you use the mail order Deductibles still apply if you fill your prescriptions at a pharmacy Home Delivery for Maintenance Medications ndash If you are taking a Maintenance Medication you may get the first 30-day supply and two 30-day refills of the same Maintenance Medication at your local Retail Pharmacy You must then contact the Home Delivery Pharmacy and tell them if you would like to keep getting your 30-day supply of Maintenance Medications from your local Retail Pharmacy or if you would like to use the Home Delivery Pharmacy You will have to pay the full retail cost of any Maintenance Medication you get without registering your choice through the Home Delivery Pharmacy You can tell us your choice by phone at the number on the back of your ID Card or by visiting our website

How to Order Your Prescription by Mail x Ask your doctor to write a prescription for each of your medication(s) that covers a 90-day supply as well as three

refills (Example If you take 2 pills per day the prescription should be written for 180 pills plus three refills) x Complete the mail order form you received in the mail with your ID card(s) You can get additional forms by going

to wwwempirebluecom or calling Empirersquos pharmacy program at the number on the back of your member ID card x Place your order for a refill at least three weeks before your current supply will run out x You will receive your filled prescription at your home within 14 working days postage paid If you prefer you can

also choose faster shipping for an additional fee

Tips for Using Mail Order The first time you fill a prescription through mail order ask your physician for a second prescription for a four-week supply You can fill the second prescription at a local pharmacy so you have the medication until the mail order is processed

MANAGE YOUR PHARMACY PLAN ONLINE Taking care of your pharmacy needs is easier than ever with Empirersquos online pharmacy If yoursquore registered for Online Member Services just go to wwwempirebluecom where you can

x Search Empirersquos drug formulary for a particular drug (by name or therapeutic category) x Locate a participating retail pharmacy near where you live or work x Order prescription refills through the mail order program x Research usage instructions drug interactions and side effects for thousands of medications

Simply log on to our web site and access your own personal secure home page Click on ldquoMy Pharmacy Planrdquo which is right next to the Rx symbol under ldquoYour Health Planrdquo

Empirersquos Pharmacy Program Customer Service 1-800-342-9816 Whatrsquos Covered The following prescription drugs are covered x Insulin and self-administered injectables x Diabetic supplies x Enteral formulas for home use that are medically

necessary and proven effective for the specific disease when prescribed by a written order by a physician or other health care provider licensed to prescribe under applicable law

x Nutritional supplements when medically necessary and proven effective for treatment

x Contraceptive drugs or devices and diaphragms x Bone mineral density drugs and devices x Refills for up to one year from the date of the original

prescription if authorized by the physician and indicated on the prescription

x Smoking cessation products by prescription only

wwwempirebluecom 33

Whatrsquos Not Covered The following items are not covered x Drugs or devices that do not require a prescription or are available over the counter except insulin and diabetic supplies x Devices of any type such as therapeutic devices IUDrsquos artificial appliances hypodermic needles syringes or similar

devices except where specifically covered and except for bone density testing and treatment devices x Charges or fees for drug administration or injection x Vitamins that by law do not require a prescription x Investigational or experimental drugs (ie medications used for experiments andor dosage levels determined by Empire

to be experimental) Refer to the Exclusions and Limitations Section and also the Complaints Appeals and Grievances Section

34 wwwempirebluecom

x Drugs received while in a hospital nursing home or other facility (covered under medical plan as indicated) x Appetite suppressants unless medically necessary x Compounded medications with no ingredients that require a prescription x Medications for cosmetic purposes only x Medications not approved by the FDA unless otherwise required by law (ie drugs that have been prescribed for the

treatment of a type of cancer for which the drug has not been approved by the FDA and not considered investigational or experimental)

x Replacement of lost stolen or damaged prescription medications x The cost for medication in excess of plan limits x Refills not dispensed in accordance with the prescription x Refills beyond one year from the original prescription date

wwwempirebluecom 35

SCHEDULE A1

Drugs Subject to Prior Authorization

Drug Class Prescription Drug

Pain Relief Abstral Arthritis Actemra Pain Relief Actiq Pulmonary Arterial Hypertension Adcirca Cancer Treatment Afinitor Psoriasis Amevive Multiple Sclerosis Ampyra Hormonal Therapy Androderm Hormonal Therapy Androgel Blood Builder Aranesp Hormonal Therapy Arixion Cancer Treatment Avastin Cervical DystoniaSpasticity Botox Immune SystemImmune Globulin Carimune NF Gaucherrsquos Disease Ceredase Gaucherrsquos Disease Cerezyme ArthritisCrohns Disease Cimzia Cervical DystoniaSpasticity Dysport Cancer Treatment Eligard ArthritisPsoriasis Enbrel Blood Builder Epogen Cancer Treatment Erbitux Arthritis Euflexxa Pain Relief Fentora Immune SystemImmune Globulin Flebogamma Pulmonary Arterial Hypertension Flolan Osteporosis Forteo Hormonal Therapy Fortesta Immune SystemImmune Globulin Gamastan Immune SystemImmune Globulin Gammagard liquid SD Immune SystemImmune Globulin Gamunex Multiple Sclerosis Gilenya Cancer Treatment Gleevac Cancer Treatment Herceptin ArthritisCrohnsPsoriasis Humira Arthritis Hyalgan Immune Deficiency Increlex Hepatitis Infergen Hepatitis Intron-A Arthritis Kineret Infection Prevention and Treatment Lamisil Blood Builder Leukine Cancer TreatmentInfertility Leuprolide Macular Degeneration Lucentis Endometriosis InfertilityCancer Lupron Depot SeizuresFibromyalgiaNerve Pain Lyrica Macular Degeneration Macugen Cervical DystoniaSpasticity Myobloc Blood Builder Neulasta Blood Builder Neumega Blood Builder Neupogen Cancer Treatment Nexavar

36 wwwempirebluecom

SCHEDULE A1 (continued)

Drugs Subject to Prior Authorization

Drug Class Prescription Drug

Excessive Sleepiness Nuvigil Immune SystemImmune Globulin Octagam Cancer Treatment Oforta Pain Relief Onsolis Arthritis Orencia Arthritis Orthovisc Immune SystemImmune Globulin Panglobulin Hepatitis Pegasys Hepatitis Peg-Intron Infection Prevention and Treatment Penlac Immune SystemImmune Globulin Polygam SD Immune SystemImmune Globulin Privigen Blood Builder Procrit Osteporosis Prolia Excessive Sleepiness Provigil Infection Prevention and Treatment Qualaquin ArthritisCrohnsPsoriasis Remicade Pulmonary Arterial Hypertension Remodulin Pulmonary Arterial Hypertension Revatio Cancer Treatment Revlimid Cancer Treatment Rituxan Hepatitis Roferon-A ArthritisPsoriasis Simponi Excessive Sleepiness Sporanox Infection Prevention and Treatment Sprycel ArthritisCrohnsPsoriasis Stelara Opiod Dependence Suboxone Arthritis Supartz Precocious Puberty Supprelin LA Cancer Treatment Sutent RSV Prevention Synagis Precocious PubertyEndometriosis Synarel Arthritis Synvisc Arthritis Synvisc One Cancer Treatment Tarceva Cancer Treatment Targretin Cancer Treatment Tasigna Cancer Treatment Temodar Hormonal Therapy Testim Cancer Treatment Thalomid Cancer Treatment Trelstar Depot LA Cancer Treatment Tykerb Pulmonary Arterial Hypertension Tyvaso Cancer Treatment Vantas Implant Cancer Treatment Vectibix Pulmonary Arterial Hypertension Ventavis Infection Prevention and Treatment Vfend Immune SystemImmune Globulin Vivaglobin Addiction Treatment Vivitrol Cancer Treatment Votrient Gaucherrsquos Disease Vpriv Cancer Treatment Xeloda

wwwempirebluecom 37

SCHEDULE A1 (continued)

Drugs Subject to Prior Authorization

Drug Class Prescription Drug

Huntingtons Disease Xenazine Bone FracturePain Due to Cancer Xgeva Arthritis Xiaflex Antibiotic Xifaxan Asthma Xolair Gaucherrsquos Disease Zavesca Cancer Treatment Zoladex Cancer Treatment Zolinza Infection Prevention and Treatment Zyvox

38 wwwempirebluecom

SCHEDULE A2

Step Therapy Drugs Subject to Prior Authorization

Drug Class Prescription Drug

Proton Pump Inhibitor Aciphex Antiacne Adoxa Antiallergy-opthalmic Alamast Non-Sedating Antihistamine Allegra ODT Suspension D Antiallergy-opthalmic Alocril Antiallergy-opthalmic Alomide Antihyperlipidemic Altoprev SedativeHypnotics Ambien CR CNS Stimulant Amphetamine Salt Combo Hypoglycemics Apidra Non-Steroidal Antiinflammatories Arthrotec Diabetes Avandament Diabetes Avandaryl Diabetes Avandia Migraine Medication Axert Diabetes Blood Glucose MetersStrips Nasal Steroids Beconase AQ Antiacne - Topical Benzaclin Multiple Sclerosis Betaseron Osteoporosis Boniva Ovulatory Stimulants Bravelle Hypoglycemics Byetta Non-Steroidal Antiinflammatories Celebrex Non-Sedating Antihistamine Clarinex-D Non-Sedating Antihistamine Clarinex Suspension Proton Pump Inhibitor Dexilant Antiacne Doryx SedativeHypnotics Edluar Antiallergy-opthalmic Elestat Dermatological Agent Elidel Antiallergy-opthalmic Emadine Overactive Bladder Agents Enablex Multiple Sclerosis Extavia Analgesics Flector Nasal Steroids Flunisolide Nasal Spray Overactive Bladder Agents Gelnique Ovulatory Stimulants Gonal-F Proton Pump Inhibitors Kapidex Antihyperlipidemic Lescol XL Antihypertensive Letairis Antihyperlipidemic Livalo Antiacne Minocin Nasal Steroids Nasacort AQ Nasal Steroids Nasarel Nasal Steroids Omnaris Antiallergy-opthalmic Optivar Overactive Bladder Agents Oxytrol Proton Pump Inhibitors pantaprazole Proton Pump Inhibitors Prilosec Proton Pump Inhibitors Prevacid Proton Pump Inhibitors Protonix Dermatological Agent Protopic

wwwempirebluecom 39

SCHEDULE A2

Step Therapy Drugs Subject to Prior Authorization (continued)

x

Drug Class Prescription Drug

Migraine Medication Relpax Nasal Steroids Rhinocort Aqua SedativeHypnotics Rozerem Antiacne Solodyn Overactive Bladder Agents Sanctura SedativeHypnotics Sonata Migraine Medication Sumavel DosePro Migraine Medication Treximet Gout Medications Uloric Hypoglycemics Victoza Antihyperlipidemics Vytorin Non-Sedating Antihistamine Xyzal Syrup Proton Pump Inhibitors Zegerid Antihyperlipidemics Zetia Skin Condition Ziana Sleep Aid Zolpimist

40 wwwempirebluecom

Exclusions and Limitations EXCLUSIONS

In addition to services mentioned under ldquoWhatrsquos Not Coveredrdquo in the prior sections your plan does not cover the following

Dental Services x Dental services including but not limited to

Cavities and extractions Care of gums Bones supporting the teeth or periodontal

abscess Orthodontia

False teeth Treatment of TMJ that is dental in nature Orthognathic surgery that is dental in nature

However your plan does cover

x Surgical removal of impacted teeth x Treatment of sound natural teeth injured by accident if treated within 12 months of the injury

ExperimentalInvestigational Treatments x Technology treatments procedures drugs biological products or medical devices that in Empirersquos judgment are

Experimental or investigative Obsolete or ineffective x Any hospitalization in connection with experimental or investigational treatments ldquoExperimentalrdquo or ldquoinvestigativerdquo

means that for the particular diagnosis or treatment of the covered personrsquos condition the treatment is Not of proven benefit Not generally recognized by the medical community (as reflected in published medical literature)

Government approval of a specific technology or treatment does not necessarily prove that it is appropriate or effective for a particular diagnosis or treatment of a covered personrsquos condition Empire may require that any or all of the following criteria be met to determine whether a technology treatment procedure biological product medical device or drug is experimental investigative obsolete or ineffective

x (FDA Approval) for the patientrsquos particular diagnosis or condition except for certain drugs prescribed for the treatment of cancer Once the FDA approves use of a medical device drug or biological product for a particular diagnosis or condition use for another diagnosis or condition may require that additional criteria be met

x Published peer review medical literature must conclude that the technology has a definite positive effect on health outcomes

x Published evidence must show that over time the treatment improves health outcomes (ie the beneficial effects outweigh any harmful effects)

x Published proof must show that the treatment at the least improves health outcomes or that it can be used in appropriate medical situations where the established treatment cannot be used Published proof must show that the treatment improves health outcomes in standard medical practice not just in an experimental laboratory setting

However your plan will cover an experimental or investigational treatment approved by an External Appeal agent certified by the state Refer to the Complaints Appeals and Grievances Section

Government Services x Services covered under government programs except Medicaid or where otherwise noted x Government hospital services except

Specific services covered in a special agreement between Empire and a government hospital United States Veteransrsquo Administration or Department of Defense Hospitals except services in connection with

a service-related disability In an emergency Empire will provide benefits until the government hospital can safely transfer the patient to a participating hospital

Home Care x Services performed at home except for those services specifically noted elsewhere in this Guide as available either at

home or as an emergency

wwwempirebluecom 41

Inappropriate Billing x Services usually given without charge even if charges are billed x Services performed by hospital or institutional staff which are billed separately from other hospital or institutional

services except as specified

Medically Unnecessary Services x Services treatment or supplies not medically necessary in Empirersquos judgment See Definitions section for more

information

Not Medically Necessary Transgender Surgery x Surgery andor treatment for gender change that does not meet our medical criteria for medical necessity

Prescription Drugs x All over the counter drugs vitamins appetite suppressants or any other type of medication unless specifically

indicated

Services Provided by a Family Member x We do not Cover services performed by a member of the covered personrsquos immediate family ldquoImmediate familyrdquo

shall mean a child spouse mother father sister or brother of You or Your Spouse

SterilizationReproductive Technologies x Reversal of sterilization x Assisted reproductive technologies including but not limited to

In-vitro fertilization Artificial insemination

Gamete and zygote intrafallopian tube transfer Intracytoplasmic sperm injection

Travel x Travel even if associated with treatment and recommended by a doctor

Vision Care x Eyeglasses contact lenses [and the examination for their fitting] except following cataract surgery unless

specifically indicated

War x Services for illness or injury received as a result of war

Workersrsquo Compensation x Services covered under Workersrsquo Compensation no-fault automobile insurance andor services covered by similar

statutory programs

LIMITATION AS INDEPENDENT CONTRACTOR The relationship between Empire BlueCross BlueShield and hospitals facilities or providers is that of independent contractors Nothing in this contract shall be deemed to create between Empire and any hospital facility or provider (or agent or employee thereof) the relationship of employer and employee or of principal and agent Empire will not be liable in any lawsuit claim or demand for damages incurred or injuries that you may sustain resulting from care received either in a hospitalfacility or from a provider

42 wwwempirebluecom

Health Management Empirersquos Medical Management Program Managing your health includes getting the information you need to make informed decisions and making sure you get the maximum benefits the plan will pay To help you manage your health Empire provides the Empirersquos Medical Management Program a service that precertifies hospital admissions and certain treatments and procedures to help ensure that you receive the highest quality of care for the right length of time in the right setting and with the maximum available coverage Empirersquos Medical Management Program works with you and your provider to help confirm the medical necessity of services and help you make sound health care decisions The program helps ensure that you and your family members receive the highest quality of care at the right time in the most appropriate setting You can contact our Medical Management program by calling the Member Services telephone number located on the back of your identification card Empire may from time to time waive enhance modify or discontinue certain medical management processes (including utilization management case management and disease management) if in Empirersquos discretion such change is in furtherance of the provision of cost effective value based andor quality services In addition we may select certain qualifying Providers to participate in a program that exempts them from certain procedural or medical management processes that would otherwise apply We may also exempt your Claim from medical review if certain conditions apply Just because Empire exempts a process Provider or Claim from the standards which otherwise would apply it does not mean that Empire will do so in the future or will do so in the future for any other Provider Claim or Member Empire may stop or modify any such exemption with or without advance notice You may determine whether a Provider is participating in certain programs by checking your on-line Provider Directory or contacting customer service number on the back of your ID card

HOW EMPIRErsquoS MEDICAL MANAGEMENT PROGRAM HELPS YOU To help ensure that you receive the maximum coverage available to you Empirersquos Medical Management Program

x Reviews all planned and emergency hospital admissions x Reviews ongoing hospitalization x Performs case management x Coordinates discharge planning x Coordinates purchase and replacement of durable medical equipment prosthetics and orthotic requirements x Reviews inpatient and ambulatory surgery x Reviews high-risk maternity admissions x Reviews care in a hospice or skilled nursing or other facility

All other services will be subject to retrospective review by our Medical Management team to determine medical necessity The health care services on the following page must be precertified with Empirersquos Medical Management Program

wwwempirebluecom 43

CALL TO PRECERTIFY THE REQUIRED SERVICEShellip

FOR ALL HOSPITAL ADMISSIONS

x At least two weeks prior to any planned surgery or hospital admission x Within 48 hours of an emergency hospital admission or as soon as reasonably possible x Of newborns for illness or injury x Before you are admitted to a rehabilitation facility or a skilled nursing facility

MATERNITY CARE

x As soon as reasonably possible we request notification within the first three months of pregnancy when possible x Within 48 hours after the actual delivery date if stay is expected to extend beyond the minimum length of stay for

mother and newborn inpatient admission forty-eight (48) hours for a vaginal birth or ninety-six (96) hours for cesarean birth

BEFORE YOU RECEIVEUSE

x Inpatient Mental Health Care Substance Abuse Care and Alcohol Detoxification x Partial Hospital Programs Psychological Testing Intensive Outpatient Programs x Occupational physical speech and vision therapy x Outpatient Ambulatory Surgical Treatments (certain procedures) x Diagnostics x Outpatient Treatments x Durable medical equipment x Air ambulance

IF SERVICES ARE NOT PRECERTIFIED If you call to precertify services as needed you will receive maximum benefits Otherwise benefits may be reduced by 50 up to $2500 for each admission treatment or procedure This benefit reduction also applies to certain same-day surgery and professional services rendered during an inpatient admission If the admission or procedure is not medically necessary no benefits will be paid

1 Preauthorization Reviews

a Non-Urgent Preauthorization Reviews If We have all the information necessary to make a determination regarding a Preauthorization review We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of receipt of the request

If We need additional information We will request it within fifteen (15) calendar days You or Your Provider will then have 45 calendar days to submit the information If We receive the requested information within 45 days We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of Our receipt of the additional information If all necessary information is not received within 45 days We will make a determination within 15 calendar days of the end of the 45 day period allowed to submit the additional information

b Urgent Preauthorization Reviews With respect to urgent Preauthorization requests if We have all

information necessary to make a determination We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within 72 hours of receipt of the request If We need additional information We will request it within 24 hours You or Your Provider will then have 48 hours to submit the information We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within 48 hours of the earlier of Our receipt of the additional information or the end of the 48-hour period allowed to submit additional information

c Court Ordered Treatment With respect to requests for mental health andor substance use disorder

services that have not yet been provided if You (or Your designee) certify in a format prescribed by the Superintendent of Financial Services that You will be appearing or have appeared before a court of competent jurisdiction and may be subject to a court order requiring such services We will make a

44 wwwempirebluecom

determination and provide notice to You (or Your designee) and Your Provider by telephone within 72 hours of receipt of the request Written notification will be provided within three (3) business days of Our receipt of the request Where feasible the telephonic and written notification will also be provided to the court

2 Concurrent Reviews

1 Non-Urgent Concurrent Reviews Utilization Review decisions for services during the course of care (concurrent reviews) will be made and notice provided to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of receipt of all necessary information If We need additional information We will request it within fifteen (15) calendar days of the receipt of the request You or Your Provider will then have 45 calendar days to submit the additional information We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of Our receipt of the additional information or if We do not receive the information within 15 calendar days of the end of the 45-day period allowed to provide the additional information

2 Urgent Concurrent Reviews For concurrent reviews that involve an extension of urgent care if the

request for coverage is made at least 24 hours prior to the expiration of a previously approved treatment We will make a determination and provide notice to You (or Your designee) and Your Provider within 24 hours of receipt of the request If the request for coverage is not made at least 24 hours prior to the expiration of a previously approved treatment We will make a determination and provide written notice to You (or Your designee) and Your Provider within 72 hours of receipt of the request If We need additional information We will request it within 24 hours You or Your Provider will then have 48 hours to submit the information We will make a determination and provide written notice to You (or Your designee) and Your Provider within the earlier of one (1) business day or 48 hours of Our receipt of the information or if We do not receive the information within 48 hours of the end of the 48-hour period

3 Inpatient Substance Use Disorder Treatment Reviews If a request for inpatient substance use disorder treatment is submitted to Us at least 24 hours prior to discharge from an inpatient substance use disorder treatment admission We will make a determination within 24 hours of receipt of the request and We will provide coverage for the inpatient substance use disorder treatment while Our determination is pending

3 Retrospective Reviews If We have all information necessary to make a determination regarding a retrospective claim We will make a determination and notify You and Your Provider within 30 calendar days of the receipt of the request If We need additional information We will request it within 30 calendar days You or Your Provider will then have 45 calendar days to provide the information We will make a determination and provide notice to You and Your Provider in writing within 15 calendar days of the earlier of Our receipt of all or part of the requested information or the end of the 45-day period

Once We have all the information to make a decision Our failure to make a Utilization Review determination within the applicable time frames set forth above will be deemed an adverse determination subject to an internal Appeal

4 Retrospective Review of Preauthorized Services We may only reverse a preauthorized treatment service

or procedure on retrospective review when x The relevant medical information presented to Us upon retrospective review is materially different

from the information presented during the Preauthorization review x The relevant medical information presented to Us upon retrospective review existed at the time of the

Preauthorization but was withheld or not made available to Us x We were not aware of the existence of such information at the time of the Preauthorization review

and x Had We been aware of such information the treatment service or procedure being requested would

not have been authorized The determination is made using the same specific standards criteria or procedures as used during the Preauthorization review

5 Reconsideration If We did not attempt to consult with Your Provider who recommended the Covered

Service before making an adverse determination the Provider may request reconsideration by the same

wwwempirebluecom 45

clinical peer reviewer who made the adverse determination or a designated clinical peer reviewer if the original clinical peer reviewer is unavailable For Preauthorization and concurrent reviews the reconsideration will take place within one (1) business day of the request for reconsideration If the adverse determination is upheld a notice of adverse determination will be given to You and Your Provider and in writing

If Empirersquos Medical Management Program does not meet the above time frames the failure should be considered a denial You or your doctor may immediately appeal

IF A REQUEST IS DENIED All denials of benefits will be rendered by qualified medical personnel If a request for care or services is denied for lack of medical necessity or because the service has been determined to be experimental or investigational Empirersquos Medical Management Program will send a notice to you and your doctor with the reasons for the denial You will have the right to appeal See section in this booklet titled ldquoComplaints Appeals and Grievancesrdquo for more information

If Empirersquos Medical Management Program denies benefits for care or services without discussing the decision with your doctor your doctor is entitled to ask Medical Management to reconsider their decision A response will be provided by telephone and in writing within one business day of making the decision

46 wwwempirebluecom

New Medical Technology REQUESTING COVERAGE

Empire uses a committee composed of Empire Medical Directors who are doctors and participating network physicians to continuously evaluate new medical technology that has not yet been designated as a covered service If you want to request certification of a new medical technology before beginning treatment your provider must contact Empirersquos Medical Management Program The provider will be asked to do the following

x Provide full supporting documentation about the new medical technology x Explain how standard medical treatment has been ineffective or would be medically inappropriate x Send us scientific peer reviewed literature that supports the effectiveness of this particular technology The literature

must not be in the form of an abstract or individual case study Empirersquos staff will evaluate the proposal in light of your contract and Empirersquos current medical policy Empire will then review the proposal taking into account relevant medical literature including current peer review articles and reviews Empire may use outside consultants if necessary If the request is complicated Empire may refer your proposal to a multi-specialty team of physicians or to a national ombudsman program designed to review such proposals Empire will send all decisions to the member andor provider

Case Management IF YOU NEED ADDITIONAL SUPPORT FOR SERIOUS ILLNESS

The Medical Management Programrsquos Case Management staff can provide assistance and support when you or a member of your family faces a chronic or catastrophic illness or injury Empirersquos nurses can help you and your family

x Find appropriate cost-effective healthcare options x Reduce medical cost x Assure quality medical care

A Case Manager serves as a single source for patient provider and insurer ndash assuring that the treatment level of care and facility are appropriate for your needs For example Case Management can help with cases such as x Cancer x Stroke x AIDS

x Chronic illness x Hemophilia x Spinal cord and other traumatic injuries

Assistance from Case Management is evaluated and provided on a case-by-case basis In some situations Empirersquos Medical Management Program staff will initiate a review of a patients health status and the attending doctors plan of care They may determine that a level of benefits not necessarily provided by this plan is desirable appropriate and cost-effective If you would like Case Management assistance following an illness or surgery contact Empirersquos Medical Management Program at 1-800-982-8089

wwwempirebluecom 47

Preventive Services Preventive Care services include Outpatient services and Office Services Screenings and other services are covered as Preventive Care for adults and children with no current symptoms or prior history of a medical condition associated with that screening or service Members who have current symptoms or have been diagnosed with a medical condition are not considered to require Preventive Care for that condition but instead benefits will be considered under the Diagnostic Services benefit Preventive Care Services in this section shall meet requirements as determined by federal law Many Preventive Care Services are covered by this Benefit Program with no Deductible Copayments or Coinsurance from the Member when provided by a Network Provider These services fall under four broad categories as shown below A Items or services with an ldquoArdquo or ldquoBrdquo rating from the United States Preventive Services Task Force

Examples of these services are screenings for Breast cancer Cervical cancer Colorectal cancer High blood pressure Type 2 diabetes mellitus Cholesterol Child and adult obesity

B Immunizations pursuant to the Advisory Committee on Immunization Practices (ldquoACIPrdquo) recommendations including

the well-child care immunizations as listed below

x DPT (diphtheria pertussis and tetanus)

x Polio

x MMR (measles mumps and rubella)

x Varicella (chicken pox)

x Hepatitis B Hemophilus

x Tetanus-diphtheria

x Pneumococcal

x Meningococcal Tetramune

x Other immunizations as determined by the Superintendent of Insurance and the Commissioner of Health in New York State or the state where your child lives

C Preventive care and screenings that are provided for in the comprehensive guidelines supported by the Health Resources

and Services Administration (ldquoHRSArdquo) including

x Well-child care visits to a pediatrician nurse or licensed nurse practitioner including a physical examination medical history developmental assessment and guidance on normal childhood development and laboratory tests The tests may be performed in the office or a laboratory Covered services and the number of visits covered per year are based on the prevailing clinical standards of the American Academy of Pediatrics (AAP) and will be determined by your childrsquos age

x Bone Density Testing and Treatment Standards for determining appropriate coverage include the criteria of the

federal Medicare program and the criteria of the National Institutes of Health for the Detection of Osteoporosis Bone mineral density measurements or tests drugs and devices include those covered under Medicare and in accordance with the criteria of the National Institutes of Health including as consistent with such criteria dual energy X-ray absorptiometry Coverage shall be available as follows

For individuals who are Ages 52 through 65 - 1 baseline Age 65 and older - 1 every 2 years (if baseline before age 65 does not indicate osteoporosis)

48 wwwempirebluecom

Under Age 65 - 1 every 2 years (if baseline before age 65 indicates osteoporosis)

For individuals who meet the criteria of the above programs including one or more of the following Previously diagnosed with or having a family history of osteoporosis Symptoms or conditions indicative of the presence or significant risk of osteoporosis Prescribed drug regimen posing a significant risk of osteoporosis Lifestyle factors to such a degree posing a significant risk of osteoporosis Age gender andor other physiological characteristics that pose a significant risk of osteoporosis

D Womenrsquos Preventive Additional preventive care and screenings for women provided for in the guidelines supported by

the Health Resources and Services Administration including the following x Well-woman care visits to a gynecologistobstetrician x Women with no prior or family history of breast cancer get a baseline mammogram between ages 35-39 and for

ages 40 and over an annual mammogram Women who have a family history of breast cancer will be covered for a routine mammogram at any age and as often as their physician recommends one

x Womenrsquos contraceptives sterilization procedures and counseling This includes contraceptive devices such as

diaphragms intra uterine devices (IUDs) and implants as well as injectable contraceptives In addition coverage is available for generic and single-source brand name prescription drugs for oral contraceptives and patches dispensed from a pharmacy To obtain benefits prescription drugs must be approved by the federal Food and Drug Administration and must be obtained from a retail or mail order pharmacy that is a member of our Pharmacy Network Please see the Oral Contraceptive Prescription Drug Rider for more information

x Breastfeeding support supplies and counseling Covered in full when received from an In-Network Provider Benefits for breast pumps are limited to one pump per Calendar Year

x Screenings andor counseling where applicable for Gestational diabetes Human Papillomavirus (HPV) sexually transmitted infections (STIs) Human immune-deficiency virus (HIV) and interpersonal and domestic violence

Screening for Prostate Cancer

We Cover an annual standard diagnostic examination including but not limited to a digital rectal examination and a prostate specific antigen test for men age 50 and over who are asymptomatic and for men age 40 and over with a family history of prostate cancer or other prostate cancer risk factors We also Cover standard diagnostic testing including but not limited to a digital rectal examination and a prostate-specific antigen test at any age for men having a prior history of prostate cancer This benefit is not subject to Copayments Deductibles or Coinsurance when provided by a Participating Provider The preventive services referenced above shall be covered in full when received from In-Network Providers Cost sharing (eg Copayments Deductibles Coinsurance) may apply to services provided during the same visit as the preventive services set forth above For example if a service referenced above is provided during an office visit wherein that service is not the primary purpose of the visit the cost-sharing amount that would otherwise apply to the office visit will still apply A list of the preventive services covered under this paragraph is available on our website at wwwempirebluecom or will be mailed to you upon request You may request the list by calling the Customer Service number on your identification card

VOLUNTARY CLINICAL QUALITY PROGRAMS The purpose of these voluntary clinical quality programs is to promote good health and early detection of disease They are designed to encourage eligible Members to obtain certain covered Preventive Care or other recommended care covered under this Certificate that was not received within the recommended timeframe For instance a program may be designed to encourage You to bring Your child to his or her PCP for a well-child or well-baby care visit if You missed a recommended check-up or may encourage You to get certain screening tests such as a mammogram if You have not been tested within the recommended age range Or a program may encourage You to have a medical visit within a specific time period such as a postpartum checkup within a set number of days after delivery of a newborn or a home visit so you can provide a blood sample for a recommended laboratory test

a Description These voluntary clinical quality programs are designed to encourage You to get certain preventive

wwwempirebluecom 49

wellness or other recommended care when You need it based on recommended clinical guidelines These programs are not guaranteed and Your participation is optional We will give You the choice and if You choose to participate in any program for which You qualify and obtain the recommended care within the programrsquos timeframe You will receive an incentive The incentive will take the form of

i a gift card in the amount of $50 or retailer coupons such as for discounts on eye glasses

ii a home test kit at no cost to allow you to conveniently collect a specimen for certain covered laboratory tests at home and mail it to the laboratory for processing In this case You may need to pay any cost shares that normally apply to covered laboratory tests under your benefit plan but the home test kit will be free to You or

iii a home visit to allow you to provide a specimen for certain covered laboratory tests or for certain biometric screenings In this care You may need to pay any cost shares that normally apply to covered laboratory tests but the home visit will be free to You

If you have any questions about whether receipt of a gift card or retailer coupon results in taxable income to You we recommend that you consult Your tax advisor

b Eligibility You the Subscriber and the Subscriberrsquos covered Spouse and each covered Dependent can

participate in the Voluntary Clinical Quality Program(s) if the targeted service applies based on the recommended clinical guidelines the program promotes These programs will be offered to Members who have certain conditions who fall within certain age ranges or who are due to receive certain recommended preventive or other care based on a recommended timeframe For example

i Members age 50-75 years who have not undergone colorectal cancer screening as recommended by the American Cancer Society may be eligible to participate in a program designed to encourage these members to obtain a recommended preventive colorectal cancer screening such as a fecal occult blood screening test

ii Members age 50-74 years who have not had a mammography screening as

recommended by the United States Preventive Services Task Force may be eligible to participate in a program designed to encourage these members to obtain the screening through the offer of a gift card awarded upon receipt of documentation that the screening was completed

c Participation If You are eligible for a clinical quality program we offer we will contact You by phone or mail to

offer You the chance to participate You may also call us at the phone number on Your ID card if You have any questions regarding program participation We will explain to You the care You are recommended to receive and the time frame within which You need to receive it to be in eligible for the reward if applicable

d Rewards Rewards for participation in a clinical quality program and completion of the identified services within the specified timeframe include monetary rewards in the form of a gift card or retailer coupon such as for discounts on eye glasses so long as the recipient is encouraged to use the reward for a product or service that promotes good health In other cases You will receive a home test kit at no cost to make it more convenient for You to receive the recommended care

50 wwwempirebluecom

Wellness Programs A Purpose The purpose of Our wellness program(s) is to encourage You to take a more active role in

managing Your health and well-being Our wellness-related programs are designed to help You achieve Your best health These programs are not Covered services under Your Plan but are separate components which are not guaranteed under Your Plan and could be discontinued at any time Participation is voluntary and You can discontinue the program at any time

B Description We provide benefits in connection with the use of or participation in any of the following wellness and health promotion actions and activities 1 Health Assessment Completion A Health Assessment is an online health tool You will answer

questions about Your lifestyle current health and history You will have access to a personal report with health tips and available online programs

x Eligibility The Subscriber and the Subscriberrsquos covered Spouse or Domestic Partner age 18 and older can participate in the program

x Participation To access the Health Assessment register or log in to Our website at wwwempirebluecom If You havenrsquot set up a user name and password select Register Now to set them up Then click on the Health amp Wellness tab and select ldquoTake my HA nowrdquo to complete the assessment On Your first visit to the site Yoursquoll be asked to give Your email address and choose health topics of interest If You do not have access to a computer please call Us at the number on Your ID card and We will provide You with information regarding how to participate without internet access We will provide You with a paper Health Assessment that will allow You to participate without computer access

2 Future Moms Future Moms is a maternity management program which provides individualized support

to expectant moms to help them achieve healthier pregnancies and deliveries The program provides education and support for high-risk and non-high-risk expectant mothers

x Eligibility The Subscriber and the Subscriberrsquos covered Spouse or Domestic Partner age 18 and older can participate in the program

x Participation Expectant moms can sign up and enroll by calling Us toll free at 800-828-5891 One of Our registered nurses will help You get started

3 Behavioral Health Resource Our Behavioral Health Resource program provides individualized support

from care managers to members with behavioral health conditions such as depression and anxiety Care managers are licensed mental health professionals whose goals are to help you take control of your health care and improve your quality of life Members have access to

x Our telephonic behavioral health resource center available 24 hours a day 7 days a week for assessment referral education coaching and crisis resolution including depression care management eating disorder management and management of other complex behavioral health concerns

x The programrsquos online and mobile app wellness tools These tools offer customized ways to address topics such as stress management anxiety depression substance abuse and chronic pain The program employs personalized tools evidence-based resources and individually-tailored eLearning programs to help members learn and practice new ways to manage their mental well-being

x Eligibility The Subscriber and each covered Dependent are eligible for the program x Participation You may call Us toll free at the number on Your ID card A care manager

will help You get started In addition We may use claims history to identify and contact potential candidates by phone to discuss whether the program is right for them

wwwempirebluecom 51

Details and Definitions In this section wersquoll cover the details you need to know to make the plan work for you Use it as a reference to understand

x Who is eligible for coverage under your plan x How to file a claim and get your benefits paid

x Your rights to appeal a claim payment or Medical Management decision

x What we mean by certain healthcare terms Knowing the details can make a difference in how satisfied you are with your plan and how easy it is for you to use If you have additional questions please visit wwwempirebluecom or call Member Services at 1-855-519-9537

Eligibility The eligibility rules and administrative procedures for adding and removing dependents for your coverage are sent out in an annually distributed official issuance of the United Nations Please do not contact Empire regarding enrollment or eligibility questions

52 wwwempirebluecom

Claims IF YOU NEED TO FILE A CLAIM

Empire makes healthcare easy by paying providers directly when you stay in-network Therefore when you receive care from providers or facilities in the Empire or BlueCard PPO networks you generally do not have to file a claim However you will have to file a claim for reimbursement for covered services received out-of-network from a non-participating provider or if you have a medical emergency out of the Empire service area To obtain a claim form call customer service

TYPE OF CLAIM IN-NETWORK OUT-OF-NETWORK

HOSPITAL Provider files claim directly with Empire or local Blue CrossBlue Shield plan

Provider files claim with Empire or local Blue CrossBlue Shield plan

MEDICAL Provider files claim directly with Empire or local Blue CrossBlue Shield plan You file claim with Empire

AMBULANCE CHARGES Provider files claim directly with Empire or local Blue CrossBlue Shield plan You file claim with Empire

At some out-of-area and non-participating hospitals you may have to pay the hospitalrsquos bill If this happens include an original itemized hospital bill with your claim

Send completed forms to

Hospital Claims

Empire BlueCross BlueShield PO Box 1407 Church Street Station New York NY 10008-1407 Attention Institutional Claims Department

Medical Claims

Empire BlueCross BlueShield PO Box 1407 Church Street Station New York NY 10008-1407 Attention Medical Claims Department

Want more claim information Now you can check the status of a claim view and print Explanation of Benefits (EOB) correct certain claim information and more at any time of day or night just by visiting wwwempirebluecom

Assignment

You authorize Empire on behalf of the Employer to make payments directly to participating In-Network Providers for Covered Services Empire also reserves the right to make payments directly to you Except where Empire expressly indicates otherwise in the case of services provided by an out of network provider payments will always be made directly to you for services provided by the out of network provider Payments may also be made to and notice regarding the receipt andor adjudication of claims an Alternate Recipient or that personrsquos custodial parent or designated representative Any payments made by Empire will discharge the Employerrsquos obligation to pay for Covered Services You cannot assign your right to receive payment to anyone else except as required by a ldquoQualified Medical Child Support orderrdquo as defined by ERISA or any applicable state or Federal law Once a Provider performs a Covered Service Empire will not honor a request to withhold payment of the claims submitted The coverage and any benefits under the Plan are not assignable by any Member without the written consent of the Plan except as provided above

wwwempirebluecom 53

Tips for Filing a Claim x File claims within 18 months of date of service x Visit wwwempirebluecom to print out a claim form immediately or contact Member Services at 1-855-519-9537

to have one mailed to you x Complete all information requested on the form x Submit all claims in English or with an English translation x Attach original bills or receipts Photocopies will not be accepted x If Empire is the secondary payer submit the original or a copy of the primary payerrsquos Explanation of Benefits (EOB)

with your itemized bill x Keep a copy of your claim form and all attachments for your records

REMEMBER File claims within 24 months of the date of service to receive benefits

IF YOU HAVE MEDICAL COVERAGE UNDER TWO PLANS (COORDINATION OF BENEFITS ndash COB) Empire has a coordination of benefits (COB) feature that applies when you and members of your family are covered under more than one health plan The benefits provided by Empire will be coordinated with any benefits you are eligible to receive under the other plan Together the plans will pay up to the amount of covered expenses but not more than the amount of actual expenses When you are covered under two plans one plan has primary responsibility to pay benefits and the other has secondary responsibility The plan with primary responsibility pays benefits first

FRAUD AND ABUSIVE BILLING We have processes to review claims before and after payment to detect fraud and abusive billing In addition We may identify certain Providers to review for potential fraud waste abuse or other inappropriate activity if the claims data suggests there may be inappropriate billing practices If a Provider is selected for review under this program then as part of the review process We may use one or more clinical utilization management guidelines in the review of claims submitted by this Provider even if those guidelines are not used for all Providers delivering services to the Planrsquos Members

Members seeking services from Non-Participating Providers could be balance billed by the Non-Participating Provider for those services that are determined to be not payable as a result of a reasonable belief of fraud or other intentional misconduct or abusive billing

Which Plan Pays Benefits First Here is how Empire determines which plan has primary responsibility for paying benefits

x If the other health plan does not have a coordination of benefits feature that plan is primary x If you are covered as an employee under the Empire plan and as a dependent under the other plan your Empire plan

is primary x For a dependent child covered under both parentsrsquo plans the primary plan is

The plan of the parent whose birthday comes earlier in the calendar year (month and day) The plan that has covered the parent for a longer period of time if the parents have the same birthday The fatherrsquos plan if the other plan does not follow the ldquobirthday rulerdquo and uses gender to determine primary

responsibility If the parents are divorced or separated (and there is no court decree establishing financial responsibility for the

childrsquos healthcare expenses) the plan covering the parent with custody is primary If the parent with custody is remarried his or her plan pays first the step-parentrsquos plan pays second and the non-

custodial parentrsquos plan pays third If the parents are divorced or separated and there is a court decree specifying which parent has financial

responsibility for the childrsquos healthcare expenses that parentrsquos plan is primary once the plan knows about the decree

x If you are actively employed your plan is primary in relation to a plan for laid-off or retired employees x If none of these rules apply the plan that has covered the patient longest is primary

If Empire Is the Secondary Plan If the Empire plan is secondary then benefits will be reduced so the total benefits paid by both plans will not be greater than the allowable expenses Also Empire will not pay more than the amount Empire would normally pay if Empire were primary

Tips for Coordinating Benefits x To receive all the benefits available to you file your claim under each plan x File claims first with the primary plan then with the secondary plan

54 wwwempirebluecom

x Include the original or a copy of the Explanation of Benefits (EOB) from the primary plan when you submit your bill to the secondary plan Remember to keep a copy for your records

If You Receive An Overpayment Of Benefits If you receive benefits that either should not have been paid or are more than should have been paid you must return any overpayment to Empire within 60 days of receiving it Overpayments include

x Payment for a service not covered by the plan x Payment for a person not covered by the plan x Payment that exceeds the amount due under your plan x Duplicate payments for the same services

Subrogation and Right of Reimbursement

These provisions apply when Plan benefits are paid as a result of injuries or illness you sustained and you have a right to a Recovery or have received a Recovery

Subrogation

The Administrator on behalf of the Employer has the right to recover Plan payments made on your behalf from any party responsible for compensating you for your injuries The following apply

x The Administrator on behalf of the Employer has the first priority for the full amount of benefits they have paid from any Recovery regardless of whether you are fully compensated and regardless of whether the payments you receive make you whole for your losses and injuries

x You and your legal representative must do whatever is necessary to enable the Administrator on behalf of the Employer to exercise their rights and do nothing to prejudice them

x The Administrator on behalf of the Employer has the right to take whatever legal action they see fit against any party or entity to recover the benefits paid under the Plan

x To the extent that the total assets from which a Recovery is available are insufficient to satisfy in full the Administrators subrogation claim and any claim still held by you The Administratorrsquos subrogation claim shall be first satisfied before any part of a Recovery is applied to your claim your attorney fees other expenses or costs

The Administrator on behalf of the Employer is not responsible for any attorney fees other expenses or costs without its prior written consent The Administrator on behalf of the Employer further agrees that the ldquocommon fundrdquo doctrine does not apply to any funds recovered by any attorney you hire regardless of whether funds recovered are used to repay benefits paid by the Administrator on behalf of the Employer

Reimbursement

If you obtain a Recovery and the Administrator on behalf of the Employer has not been repaid for the benefits the Administrator on behalf of the Employer paid on your behalf the Administrator on behalf of the Employer shall have a right to be repaid from the Recovery in the amount of the benefits paid on your behalf and the following apply

x You must reimburse the Administrator on behalf of the Employer to the extent of Plan benefits the Administrator on behalf of the Employer paid on your behalf from any Recovery

x Notwithstanding any allocation made in a settlement agreement or court order the Administrator on behalf of the Employer shall have a right of Recovery in first priority against any Recovery

x You and your legal representative must hold in trust for the Administrator on behalf of the Employer the proceeds of the gross Recovery (ie the total amount of your Recovery before attorney fees other expenses or costs) to be paid to the Administrator on behalf of the Employer immediately upon your receipt of the Recovery You must reimburse the Employer in first priority and without any set-off or reduction for attorney fees other expenses or costs The ldquocommon fundrdquo doctrine does not apply to any funds recovered by any attorney You hire regardless of whether funds recovered are used to repay benefits paid by the Administrator on behalf of the Employer

x If You fail to repay the Administrator on behalf of the Employer the Administrator on behalf of the Employer shall be entitled to deduct any of the unsatisfied portion of the amount of benefits the Administrator on behalf of the Employer has paid or the amount of your Recovery whichever is less from any future benefit under the Plan if The amount the Administrator on behalf of the Employer paid on your behalf is not repaid or otherwise

recovered by the Administrator on behalf of the Employer or You fail to cooperate

x In the event that You fail to disclose to the Administrator andor the Employer the amount of your settlement the Administrator on behalf of the Employer shall be entitled to deduct the amount of their lien from any future benefit under the Plan

wwwempirebluecom 55

x The Administrator on behalf of the Employer shall also be entitled to recover any of the unsatisfied portions of the amount they have paid or the amount of your settlement whichever is less directly from the Providers to whom the Administrator on behalf of the Employer has made payments In such a circumstance it may then be your obligation to pay the Provider the full billed amount and the Administrator on behalf of the Employer would not have any obligation to pay the Provider

The Administrator on behalf of the Employer is entitled to reimbursement from any Recovery in first priority even if the Recovery does not fully satisfy the judgment settlement or underlying claim for damages or fully compensate or make you whole

Your Duties

x You must notify the Administrator on behalf of the Employer promptly of how when and where an accident or incident resulting in personal injury or illness to you occurred and all information regarding the parties involved

x You must cooperate with the Administrator on behalf of the Employer in the investigation settlement and protection of the Employers rights of the Administrator on behalf of the Employer

x You must not do anything to prejudice the rights of the Administrator on behalf of the Employer x You must send the Administrator on behalf of the Employer copies of all police reports notices or other papers

received in connection with the accident or incident resulting in personal injury or illness to you x You must promptly notify the Administrator on behalf of the Employer if you retain an attorney or if a lawsuit is

filed on your behalf

Health Care Fraud Illegal activity adds to everyonersquos cost for healthcare Thatrsquos why Empire welcomes your help in fighting fraud If you know of any person receiving Empire benefits that they are not entitled to call us We will keep your identity confidential Want to see some recent examples of Empirersquos fraud prevention efforts Visit wwwempirebluecom

REMEMBER FRAUD HOTLINE 1-800-ICFRAUD (423-7283) During normal business hours

If You Have Questions About a Benefit Payment Empire reviews each claim for appropriate services and correct information before it is paid Once a claim is processed an Explanation of Benefits (EOB) will be sent directly to you if you have any responsibility on the claim other than your co-payment amount or if an adjustment is performed on your claim If Empire reduces or denies a claim payment you will receive a written notification or an Explanation of Benefits (EOB) citing the reasons your claim was reduced or denied The notification will give you

x The specific reason(s) for the denial x References to the pertinent plan provisions on which the denial is based x A description of any additional material or information necessary for you to establish the claim and an explanation of

why this material or information is necessary x An explanation of claims review procedures

If you have any questions about your claim your Benefits Administrator may be able to help you answer them You may also contact Empire Member Services at 1-855-519-9537 or in writing for more information When you call be sure to have your Empire ID card number handy along with any information about your claim Send written inquiries to

Empire BlueCross BlueShield PPO Member Services PO Box 1407 Church Street Station New York NY 10008-1407

56 wwwempirebluecom

Reimbursement For Covered Services Maximum Allowed Amount This section describes how We determine the amount of reimbursement for Covered Services Reimbursement for services rendered by In-Network and Out-of-Network Providers is based on the Maximum Allowed Amount for the Covered Service that you receive Please see the Blue Cross and Blue Shield Association BlueCard Program section for additional information regarding services received outside of Empirersquos service area

The Maximum Allowed Amount is the maximum amount of reimbursement Empire will pay for services and supplies

x that meet our definition of Covered Services to the extent such services and supplies are covered under Your

Plan and are not excluded x that are Medically Necessary and x that are provided in accordance with all applicable preauthorization Medical Management Programs or other

requirements set forth in Your Plan You will be required to pay a portion of the Maximum Allowed Amount to the extent you have not met your Deductible or have a Copayment or Coinsurance In addition when you receive Covered Services from an Out-of-Network Provider you may be responsible for paying any difference between the Maximum Allowed Amount and the Providerrsquos actual charges This amount can be significant

When you receive Covered Services from a Provider We will to the extent applicable apply claim processing rules to the claim submitted for those Covered Services These rules evaluate the claim information and determine among other things the appropriateness of the procedure and diagnosis codes included in the claim Applying these rules may affect our determination of the Maximum Allowed Amount Our application of these rules does not mean that the Covered Services you received were not Medically Necessary It means We have determined that the claim submitted was inconsistent with procedure coding rules andor our reimbursement policies For example your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed When this occurs the Maximum Allowed Amount will be based on the single procedure code rather than a separate Maximum Allowed Amount for each billed code Likewise when multiple procedures are performed on the same day by the same Provider or other healthcare professional We may reduce the Maximum Allowed Amounts for those secondary and subsequent procedures because reimbursement at 100 of the Maximum Allowed Amount for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive

PROVIDER NETWORK STATUS The Maximum Allowed Amount may vary depending upon whether the Provider is an In-Network Provider or an Out-of-Network Provider

For Covered Services performed by an In-Network Provider the Maximum Allowed Amount is the rate the Provider has agreed with Empire to accept as reimbursement for the Covered Services Because In-Network Providers have agreed to accept the Maximum Allowed Amount as payment in full for that service they should not send you a bill or collect for amounts above the Maximum Allowed Amount However you may receive a bill or be asked to pay all or a portion of the Maximum Allowed Amount to the extent that you have not met your Deductible or have a Copayment or Coinsurance Please call Customer Service for help in finding an In-Network Provider or visit wwwempirebluecom

Providers who have not signed any contract with Us and are not in any of our networks are Out-of-Network Providers subject to Blue Cross and Blue Shield Association rules governing claims filed by certain ancillary Providers

For Covered Services that you receive from an Out-of-Network Provider the Maximum Allowed Amount will be based on our Out-of-Network Provider fee schedulerate or the Out-of-Network Providerrsquos charge this amount is currently 275 of Medicarersquos Fee Schedule whichever is less (except Certified Social Worker 225 and Physical Therapy 200) Our Out-of-Network Provider fee schedulerate may be accessed by calling the Customer Service number on the back of your identification card The Maximum Allowed Amount on our Out-of-Network Provider fee schedulerate has been developed by reference to one or more of several sources including the following

wwwempirebluecom 57

1 Amounts based on our In-Network Provider fee schedulerate 2 Amounts based on the level andor method of reimbursement used by the Centers for Medicare and Medicaid

Services unadjusted for geographic locality for the same services or supplies Such reimbursement amounts will be updated no less than annually

3 Amounts based on charge cost reimbursement or utilization data 4 Amounts based on information provided by a third party vendor which may reflect one or more of the

following factors i) the complexity or severity of treatment ii) level of skill and experience required for the treatment or iii) comparable Providersrsquo fees and costs to deliver care or

5 An amount negotiated by the Claims Administrator or a third party vendor which has been agreed to by the Provider This may include rates for services coordinated through case management

The amount We pay a Non-Participating Provider for Emergency Services will be the greater of 1) the amount We have negotiated with Participating Providers for the Emergency Service (and if more than one amount is negotiated the median of the amounts) 2) 100 of the Allowed Amount for services provided by a Non-Participating Provider (ie the amount We would pay in the absence of any Cost-Sharing that would otherwise apply for services of Non-Participating Providers) or 3) the amount that would be paid under Medicare The amounts described above exclude any Copayment or Coinsurance that applies to Emergency Services provided by a Participating Provider For Covered Services rendered outside Empirersquos Service Area by Out-of-Network Providers claims may be priced using the local Blue Cross Blue Shield planrsquos non-participating provider fee schedule rate or the pricing arrangements required by applicable state or federal law In certain situations the Maximum Allowed Amount for out of area claims may be based on billed charges the pricing we would use if the healthcare services had been obtained within the Empire Service Area or a special negotiated price

Providers who are not contracted for this Plan but contracted for other Plans with Us are also considered Out-of-Network The Maximum Allowed Amount reimbursement for services from these Providers will be based on Our Out-of Network Provider fee schedulerate as described above unless the contract between Us and that Provider specifies a different amount

Unlike In-Network Providers Out-of-Network Providers may send you a bill and collect for the amount of the Providerrsquos charge that exceeds our Maximum Allowed Amount You are responsible for paying the difference between the Maximum Allowed Amount and the amount the Provider charges This amount can be significant Choosing an In-Network Provider will likely result in lower out of pocket costs to you Please call Customer Service for help in finding In-Network Providers or visit our website at wwwempirebluecom

Customer Service is also available to assist you in determining the Maximum Allowed Amount for a particular service from an Out-of-Network Provider In order for Us to assist you you will need to obtain from your Provider the specific procedure code(s) and diagnosis code(s) for the services the Provider will render You will also need to know the Providerrsquos charges to calculate your out of pocket responsibility Although Customer Service can assist you with this pre-service information the final Maximum Allowed Amount for your claim will be based on the actual claim submitted

MEMBER COST SHARE For certain Covered Services and depending on Your Plan you may be required to pay a part of the Maximum Allowed Amount as your cost share amount (for example Deductible Copayment andor Coinsurance)

Your cost share amount and out-of-pocket limit may vary depending on whether you received services from an In-Network or an Out-of-Network Provider Specifically you may be required to pay higher cost sharing amounts or may have limits on your benefits when using Out-of-Network Providers Please see the terms of this Benefit Booklet and Benefits At A Glance chart for your cost share amounts and limitations or call Customer Service to learn how Your Planrsquos benefits or cost share amounts may vary by the type of Provider you use

Empire will not provide any reimbursement for non-Covered Services You may be responsible for the total amount billed by your Provider for non-Covered Services regardless of whether such services are performed by an In-Network Provider or an Out-of-Network Provider Both services specifically excluded by the terms of Your Plan and those received after benefits have been exhausted are non-Covered Services Benefits may be exhausted by exceeding for example your lifetime maximum benefit caps or dayvisit limits Note that no Out-of-Network coverage is available for benefits that are listed as In-Network only in Your Plan

In some instances you may only be asked to pay the lower In-Network cost sharing amount when you use an Out-of-Network Provider For example if you go to an In-Network Hospital or Facility and receive Covered Services from an Out-of-Network

58 wwwempirebluecom

Provider such as a radiologist anesthesiologist or pathologist who is employed by or contracted with an In-Network Hospital or Facility you will pay the In-Network cost share amounts for those Covered Services However you also may be liable for the difference between the Maximum Allowed Amount and the Out-of-Network Providerrsquos charge

The following are examples for illustrative purposes only Please see Your Benefits At A Glance for Your applicable amounts

Example Your Plan has Coinsurance of 20 for In-Network services and 30 Out-of-Network after the In- or Out-of-Network Deductible has been met You undergo a surgical procedure in an In-Network Hospital The Hospital has contracted with an Out-of-Network anesthesiologist to perform the anesthesiology services for the surgery You have no control over the anesthesiologist used

The Out-of-Network anesthesiologistrsquos charge for the service is $1200 The Maximum Allowed Amount for the anesthesiology service is $950 your Coinsurance responsibility is 20 of $950 or $190 and the remaining allowance from Us is 80 of $950 or $760 You may receive a bill from the anesthesiologist for the difference between $1200 and $950 Provided the Deductible has been met your total out of pocket responsibility would be $190 (20 Coinsurance responsibility) plus an additional $250 for a total of $440 You choose an In-Network surgeon The charge is $2500 The Maximum Allowed Amount for the surgery is $1500 your Coinsurance when an In-Network surgeon is used is 20 of $1500 or $300 We allow 80 of $1500 or $1200 The In-Network surgeon accepts the total of $1500 as reimbursement for the surgery regardless of the charges Your total out of pocket responsibility would be $300 You choose an Out-of-Network surgeon The Out-of-Network surgeonrsquos charge for the service is $2500 The Maximum Allowed Amount for the surgery service is $1500 your Coinsurance for the Out-of-Network surgeon is 30 of $1500 or $450 after the Out-of-Network Deductible has been met We allow the remaining 70 of $1500 or $1050 In addition the Out-of-Network surgeon could bill you the difference between $2500 and $1500 so your total out of pocket charge would be $450 plus an additional $1000 for a total of $1450

AUTHORIZED SERVICES In some circumstances such as where there is no In-Network Provider available for the Covered Service We may authorize the In-Network cost share amounts (Deductible Copayment andor Coinsurance) to apply to a claim for a Covered Service you receive from an Out-of-Network Provider In such circumstance you must contact Us in advance of obtaining the Covered Service We will authorize the In-Network cost share amounts to apply to a claim for Covered Services if you receive Emergency services from an Out-of-Network Provider consistent with applicable state and federal regulations on Emergency Services If We authorize an Out-of-Network Covered Service so that you are responsible for the In-Network cost share amounts you may still be liable for the difference between the Maximum Allowed Amount and the Out-of-Network Providerrsquos charge Please contact Customer Service for information or to request authorization

The following are examples for illustrative purposes only Please see Your Benefits At A Glance chart for Your applicable amounts

Example You require the services of a specialist but there is no In-Network Provider for that specialty in your state of residence You contact Us in advance of receiving any Covered Services and We authorize you to go to an available Out-of-Network Provider for that Covered Service and We agree that the In-Network cost share will apply

Your Plan has a 30 Coinsurance for Out-of-Network Providers and a $25 Copayment for In-Network Providers for the Covered Service The Out-of-Network Providerrsquos charge for this service is $500 The Maximum Allowed Amount is $200

Because We have authorized the In-Network cost share amount to apply in this situation you will be responsible for the In-Network Copayment of $25 and Empire will be responsible for the remaining $175 of the $200 Maximum Allowed Amount

Because the Out-of-Network Providerrsquos charge for this service is $500 you may receive a bill from the Out-of-Network Provider for the difference between the $500 charge and the Maximum Allowed Amount of $200 Combined with your In-Network Copayment of $25 your total out of pocket expense would be $325

wwwempirebluecom 59

Complaints Appeals and Grievances Grievance Procedures A Grievances Our Grievance procedure applies to any issue not relating to a Medical Necessity or

experimental or investigational determination by Us For example it applies to contractual benefit denials or issues or concerns You have regarding Our administrative policies or access to Providers

B Filing a Grievance You can contact Us by phone at the number on Your ID card in person or in writing

to file a Grievance You may submit an oral Grievance in connection with a denial of a Referral or a covered benefit determination We may require that You sign a written acknowledgement of Your oral Grievance prepared by Us You or Your designee has up to 180 calendar days from when You received the decision You are asking Us to review to file the Grievance

When We receive Your Grievance We will mail an acknowledgment letter within 15 business days The acknowledgment letter will include the name address and telephone number of the person handling Your Grievance and indicate what additional information if any must be provided

We keep all requests and discussions confidential and We will take no discriminatory action because of Your issue We have a process for both standard and expedited Grievances depending on the nature of Your inquiry

C Grievance Determination Qualified personnel will review Your Grievance or if it is a clinical matter a

licensed certified or registered Health Care Professional will look into it We will decide the Grievance and notify You within the following timeframes

ExpeditedUrgent Grievances By phone within the earlier of 48 hours of receipt of all

necessary information or 72 hours of receipt of Your Grievance Written notice will be provided within 72 hours of receipt of Your Grievance

Pre-Service Grievances (A request for a service or treatment that has not yet been provided)

In writing within 15 calendar days of receipt of Your Grievance

Post-Service Grievances (A claim for a service or treatment that has already been provided)

In writing within 30 calendar days of receipt of Your Grievance

All Other Grievances (That are not in relation to a claim or request for a service or treatment)

In writing within 45 calendar days of receipt of all necessary information but no more than 60 calendar days of receipt of Your Grievance

D Grievance Appeals If You are not satisfied with the resolution of Your Grievance You or Your

designee may file an Appeal by phone at the number on Your ID card in person or in writing You have up to 60 business days from receipt of the Grievance determination to file an Appeal

When We receive Your Appeal We will mail an acknowledgment letter within 15 business days The acknowledgement letter will include the name address and telephone number of the person handling Your Appeal and indicate what additional information if any must be provided

One or more qualified personnel at a higher level than the personnel that rendered the Grievance determination will review it or if it is a clinical matter a clinical peer reviewer will look into it We will decide the Appeal and notify You in writing within the following timeframes

ExpeditedUrgent Grievances The earlier of two (2) business days of receipt of all

60 wwwempirebluecom

necessary information or 72 hours of receipt of Your Appeal

Pre-Service Grievances (A request for a service or treatment that has not yet been provided)

15 calendar days of receipt of Your Appeal

Post-Service Grievances (A claim for a service or treatment that has already been provided)

30 calendar days of receipt of Your Appeal

All Other Grievances (That are not in relation to a claim or request for a service or treatment)

30 business days of receipt of all necessary information to make a determination

Utilization Review 1 Utilization Review We review health services to determine whether the services are or were Medically

Necessary or experimental or investigational (Medically Necessary) This process is called Utilization Review Utilization Review includes all review activities whether they take place prior to the service being performed (Preauthorization) when the service is being performed (concurrent) or after the service is performed (retrospective) If You have any questions about the Utilization Review process please call the number on Your ID card The toll-free telephone number is available at least 40 hours a week with an after-hours answering machine

All determinations that services are not Medically Necessary will be made by 1) licensed Physicians or 2) licensed certified registered or credentialed Health Care Professionals who are in the same profession and same or similar specialty as the Provider who typically manages Your medical condition or disease or provides the health care service under review or 3) with respect to mental health or substance use disorder treatment licensed Physicians or licensed certified registered or credentialed Health Care Professionals who specialize in behavioral health and have experience in the delivery of mental health or substance use disorder courses of treatment We do not compensate or provide financial incentives to Our employees or reviewers for determining that services are not Medically Necessary We have developed guidelines and protocols to assist Us in this process For substance use disorder treatment We will use evidence-based and peer reviewed clinical review tools designated by OASAS that are appropriate to the age of the patient Specific guidelines and protocols are available for Your review upon request For more information call the number on Your ID card or visit Our website at wwwempirebluecom

2 Utilization Review Internal Appeals You Your designee and in retrospective review cases Your

Provider may request an internal Appeal of an adverse determination either by phone in person or in writing

You have up to 180 calendar days after You receive notice of the adverse determination to file an Appeal We will acknowledge Your request for an internal Appeal within 15 calendar days of receipt This acknowledgment will include the name address and phone number of the person handling Your Appeal and if necessary inform You of any additional information needed before a decision can be made The Appeal will be decided by a clinical peer reviewer who is not subordinate to the clinical peer reviewer who made the initial adverse determination and who is 1) a Physician or 2) a Health Care Professional in the same or similar specialty as the Provider who typically manages the disease or condition at issue

1 Out-of-Network Service Denial You also have the right to Appeal the denial of a Preauthorization

request for an out-of-network health service when We determine that the out-of-network health service is not materially different from an available in-network health service A denial of an out-of-network health service is a service provided by a Non-Participating Provider but only when the service is not available from a Participating Provider For a Utilization Review Appeal of denial of an out-of-network health service You or Your designee must submit

x A written statement from Your attending Physician who must be a licensed board-certified or board-eligible Physician qualified to practice in the specialty area of practice appropriate to treat Your condition that the requested out-of-network health service is materially different from the alternate health service available from a Participating Provider that We approved to treat Your condition and

wwwempirebluecom 61

x Two (2) documents from the available medical and scientific evidence that the out-of-network service 1) is likely to be more clinically beneficial to You than the alternate in-network service and 2) that the adverse risk of the out-of-network service would likely not be substantially increased over the in-network health service

2 Out-of-Network Authorization Denial You also have the right to Appeal the denial of a request for an

authorization to a Non-Participating Provider when We determine that We have a Participating Provider with the appropriate training and experience to meet Your particular health care needs who is able to provide the requested health care service For a Utilization Review Appeal of an out-of-network authorization denial You or Your designee must submit a written statement from Your attending Physician who must be a licensed board-certified or board-eligible Physician qualified to practice in the specialty area of practice appropriate to treat Your condition

x That the Participating Provider recommended by Us does not have the appropriate training and experience to meet Your particular health care needs for the health care service and

x Recommending a Non-Participating Provider with the appropriate training and experience to meet Your particular health care needs who is able to provide the requested health care service

3 First Level Appeal

1 Preauthorization Appeal If Your Appeal relates to a Preauthorization request We will decide the Appeal

within 15 calendar days of receipt of the Appeal request Written notice of the determination will be provided to You (or Your designee) and where appropriate Your Provider within two (2) business days after the determination is made but no later than 15 calendar days after receipt of the Appeal request

2 Retrospective Appeal If Your Appeal relates to a retrospective claim We will decide the Appeal within

30 calendar days of receipt of the Appeal request Written notice of the determination will be provided to You (or Your designee) and where appropriate Your Provider within two (2) business days after the determination is made but no later than 30 calendar days after receipt of the Appeal request

3 Expedited Appeal An Appeal of a review of continued or extended health care services additional

services rendered in the course of continued treatment home health care services following discharge from an inpatient Hospital admission services in which a Provider requests an immediate review mental health andor substance use disorder services that may be subject to a court order or any other urgent matter will be handled on an expedited basis An expedited Appeal is not available for retrospective reviews For an expedited Appeal Your Provider will have reasonable access to the clinical peer reviewer assigned to the Appeal within one (1) business day of receipt of the request for an Appeal Your Provider and a clinical peer reviewer may exchange information by telephone or fax An expedited Appeal will be determined within the earlier of 72 hours of receipt of the Appeal or two (2) business days of receipt of the information necessary to conduct the Appeal

If You are not satisfied with the resolution of Your expedited Appeal You may file a standard internal Appeal or an external review Our failure to render a determination of Your Appeal within 30 calendar days of receipt of the necessary information for a standard Appeal or within two (2) business days of receipt of the necessary information for an expedited Appeal will be deemed a reversal of the initial adverse determination

Substance Use Appeal If We deny a request for inpatient substance use disorder treatment that was submitted at least 24 hours prior to discharge from an inpatient admission and You or Your Provider file an expedited internal Appeal of Our adverse determination We will decide the Appeal within 24 hours of receipt of the Appeal request If You or Your Provider file the expedited internal Appeal and an expedited external review within 24 hours of receipt of Our adverse determination We will also provide coverage for the inpatient substance use disorder treatment while a determination on the internal Appeal and external review is pending

4 Second Level Appeal If You disagree with the first level Appeal determination You or Your designee can file a second level Appeal You or Your designee can also file an external review The four (4) month timeframe for filing an external review begins on receipt of the final adverse determination on the first level of Appeal By choosing to file a second level Appeal the time may expire for You to file for external review

62 wwwempirebluecom

A second level Appeal must be filed within 60 days of receipt of the final adverse determination on the first level Appeal We will acknowledge Your request for an internal Appeal within 15 calendar days of receipt This acknowledgment will include the name address and phone number of the person handling Your Appeal and inform You if necessary of any additional information needed before a decision can be made

1 Preauthorization Appeal If Your Appeal relates to a Preauthorization request We will decide the

Appeal within 15 calendar days of receipt of the Appeal request Written notice of the determination will be provided to You (or Your designee) and where appropriate Your Provider within two (2) business days after the determination is made but no later than 15 calendar days after receipt of the Appeal request

2 Retrospective Appeal If Your Appeal relates to a retrospective claim We will decide the Appeal within

30 calendar days of receipt of the Appeal request Written notice of the determination will be provided to You (or Your designee) and where appropriate Your Provider within two (2) business days after the determination is made but no later than 30 calendar days after receipt of the Appeal request

3 Expedited Appeal If Your Appeal relates to an urgent matter We will decide the Appeal and provide written notice of the determination to You (or Your designee) and where appropriate Your Provider within 72 hours of receipt of the Appeal request ]

External Review

A If the outcome of the mandatory first level appeal is adverse to you you may be eligible for an independent

External Review pursuant to federal law You must submit your request for External Review to the Claims Administrator within four (4) months of the notice of your final internal adverse determination A request for an External Review must be in writing unless the Claims Administrator determines that it is not reasonable to require a written statement You do not have to re-send the information that you submitted for internal appeal However you are encouraged to submit any additional information that you think is important for review

B For pre-service claims involving urgentconcurrent care you may proceed with an Expedited External Review without filing an internal appeal or while simultaneously pursuing an expedited appeal through our internal appeal process You or your authorized representative may request it orally or in writing All necessary information including the Claims Administratorrsquos decision can be sent between the Claims Administrator and you by telephone facsimile or other similar method To proceed with an Expedited External Review you or your authorized representative must contact the Claims Administrator at the number shown on your identification card and provide at least the following information

x the identity of the claimant x the date (s) of the medical service x the specific medical condition or symptom x the providerrsquos name x the service or supply for which approval of benefits was sought and x any reasons why the appeal should be processed on a more expedited basis

C All other requests for External Review should be submitted in writing unless the Claims Administrator

determines that it is not reasonable to require a written statement Such requests should be submitted by you or your authorized representative to

Empire Appeal and Grievance Department PO Box 1407

Church Street Station New York NY 10008-1407

This is not an additional step that you must take in order to fulfill your appeal procedure obligations described above Your decision to seek External Review will not affect your rights to any other benefits under this health care plan There is no charge for you to initiate an independent External Review The External Review decision is final and binding on all parties except for any relief available through applicable state laws or ERISA

wwwempirebluecom 63

Ending and Continuing Coverage WHEN COVERAGE ENDS

Your Empire plan coverage may terminate for any of the following reasons x Your group terminates the contract x Your employer no longer meets our underwriting standards x Your employer fails to pay premiums x You fail to pay premiums (if required) x The covered employee dies x You or your covered dependents no longer meet your employerrsquos or the contractrsquos eligibility requirements x You or your covered dependents have made a false statement on an application for coverage or on a health insurance

claim form or you or your group have otherwise engaged in fraud x Empire discontinues this class of coverage

CONTINUING COVERAGE UNDER NEW YORK STATE LAW If you are not entitled to continuation of coverage under COBRA (for example your employer has fewer than 20 employees) you may be entitled to continue coverage under New York State Law These laws vary from those under COBRA but generally also require continued coverage for up to 18 29 or 36 months Call or write to your employer or Empire to find out if you are entitled to continuation of coverage under the New York State Insurance Law

THE VETERANS BENEFITS IMPROVEMENT ACT OF 2004 The Veterans Benefits Improvement Act of 2004 which amends the 1994 Uniformed Services Employment and Reemployment Rights Act (USERRA) extends the period for continuation of health care coverage as follows

If a covered persons health plan coverage would terminate because of an absence due to military service the person may elect to continue the health plan coverage for up to 24 months after the absence begins or for the period of service Similar to COBRA the person cannot be required to pay more than 102 percent (except where State requirements provide for a lesser amount) of the full premium for the coverage If military service was for 30 or fewer days the person cannot be required to pay more than the normal employee share of any premium

ENDING AND CONTINUING COVERAGE Your EmployerPlan Sponsor reserves the right to amend or terminate its group health plan coverage provided to you at any time without prior notice or approval The decision to end or amend the health plan coverage may be due to changes in federal or state laws governing welfare benefits the requirements of the Internal Revenue Code or ERISA or any other reason

Any amendment or termination may apply to all or any portion of the group health plan coverage and to all or to only a portion of the participants and beneficiaries

Certificates of Creditable Coverage After Termination Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) a certificate of coverage must be issued to a Member and his or her covered Dependents who terminate from this Benefit Program The information included on the Certificate of Creditable Coverage will include the names of any Members terminating the date coverage under this Benefit Program ended and the type of coverage provided under this Benefit Program This Certificate of Creditable Coverage will provide a subsequent insurer or group Plan with information regarding previous coverage to assist it in determining any Pre-Existing Condition exclusion period or Affiliation Period This Certificate of Creditable Coverage should be presented by the Member to his or her next Employer Group andor when applying for subsequent group health insurance A Certificate of Creditable Coverage will be issued to terminating Members within a reasonable amount of time after Empire has terminated membership In addition a terminated Member may request an additional copy of the Certificate of Creditable Coverage by contacting Member Services

64 wwwempirebluecom

ACCESS TO INFORMATION

In addition to calling Member Services for claim and benefit information you can contact them for x The names business addresses and official positions of Empirersquos Board of Directors officers controlling persons

owners and partners x Empirersquos most recently published annual financial statement x A consumer report of grievances filed with the Insurance Superintendent x Procedures that protect confidentiality of medical records and information x A copy of Empirersquos Drug Formulary x A directory of participating providers x A description of our quality assurance program x A notice of specific individual provider affiliations with participating hospitals x Upon written request specific written clinical criteria for determining if a procedure or test is medically necessary

For Members Who Donrsquot Speak English Empire will help members who speak languages other than English ask questions and file grievances in their first language When you call Member Services the operator will link you to an interpreter in your preferred language who can facilitate the discussion 247 NurseLine is also equipped to provide assistance in most languages

wwwempirebluecom 65

Your Rights and Responsibilities

We are committed to

x Recognizing and respecting you as a member x Encouraging your open discussions with your health care professionals and providers x Providing information to help you become an informed health care consumer x Providing access to health benefits and our network providers x Sharing our expectations of you as a member

You have the right to

x Participate with your health care professionals and providers in making decisions about your health care x Receive the benefits for which you have coverage x Be treated with respect and dignity x Privacy of your personal health information consistent with state and federal laws and our policies x Receive information about our organization and services our network of health care professionals and providers

and your rights and responsibilities x Candidly discuss with your physicians and providers appropriate or medically necessary care for your condition

regardless of cost or benefit coverage x Make recommendations regarding the organizations members rights and responsibilities policies x Voice complaints or appeals about our organization any benefit or coverage decisions we (or our designated

administrators) make your coverage or care provided x Refuse treatment for any condition illness or disease without jeopardizing future treatment and be informed by

your physician(s) of the medical consequences x Participate in matters of the organizationrsquos policy and operations x The member has the right to obtain complete and current information concerning a diagnosis treatment and

prognosis from a physician or other provider in terms that the member can be reasonably expected to understand When it is not advisable to give such information to the member the information will be made available to an appropriate person acting on the members behalf

You have the responsibility to

x Choose a participating primary care physician if required by your health benefit plan x Treat all health care professionals and staff with courtesy and respect x Keep scheduled appointments with your doctor and call the doctorrsquos office if you have a delay or cancellation x Read and understand to the best of your ability all materials concerning your health benefits or ask for help if you

need it x Understand your health problems and participate along with your health care professionals and providers in

developing mutually agreed upon treatment goals to the degree possible x Supply to the extent possible information that we andor your health care professionals and providers need in order

to provide care x Follow the plans and instructions for care that you have agreed on with your health care professional and provider x Tell your health care professional and provider if you do not understand your treatment plan or what is expected of

you x Follow all health benefit plan guidelines provisions policies and procedures x Let our Customer Service Department know if you have any changes to your name address or family members

covered under your policy x Provide us with accurate and complete information needed to administer your health benefit plan including other

health benefit coverage and other insurance benefits you may have in addition to your coverage with us We are committed to providing quality benefits and customer service to our members Benefits and coverage for services provided under the benefit program are governed by the Subscriber Agreement and not by this Member Rights and Responsibilities statement

66 wwwempirebluecom

Definitions

Refer to these definitions to help you better understand your coverage Need more help Additional terms and definitions can be viewed at wwwempirebluecom

Adverse Determination A communication from Empirersquos Medical Management that reduces or denies benefits

Annual Out-of-Pocket Limit The most you pay during a Benefit Period in cost sharing before your Plan begins to pay 100 of the Maximum Allowed Amount for Covered Services The Annual Out-of-Pocket Limit does not include your Premium amounts over the Maximum Allowed Amount or charges for services that your Plan does not cover The Annual Out-of-Pocket Limit may consist of Deductibles Coinsurance andor Copayments Please see the ldquoYour Benefits At A Glancerdquo section for cost shares that apply to Your Plan

Authorized Services See ldquoprecertified servicesrdquo

Co-payment The fee you pay for office visits and certain covered services when you use in-network providers The plan then pays 100 of remaining covered expenses

Covered Services The services for which Empire provides benefits under the terms of your contract For example Empire covers one in-network annual physical exam

Deductible The dollar amount you must pay each calendar year before your plan pays benefits for covered out-of-network services If you have family coverage once the first family member meets the individual deductible the plan will pay benefits for that family member However the benefits for other family members will not be paid until two or more eligible family members meet the family deductible Once the family deductible is met your PPO plan will pay benefits for covered out-of-network services for the remainder of the year for all eligible family members The exception to this rule is a common accident benefit ndash if two or more family members are injured in the same accident and require medical care the family must meet only one individual deductible

HospitalFacility For purposes of certifying inpatient services a hospital or facility must be a fully licensed acute-care general facility that has all of the following on its own premises

x A broad scope of major surgical medical therapeutic and diagnostic services available at all times to treat almost all illnesses accidents and emergencies

x 24-hour general nursing service with registered nurses who are on duty and present in the hospital at all times x A fully-staffed operating room suitable for major surgery together with anesthesia service and equipment The

hospital must perform major surgery frequently enough to maintain a high level of expertise with respect to such surgery in order to ensure quality care

x Assigned emergency personnel and a ldquocrash cartrdquo to treat cardiac arrest and other medical emergencies x Diagnostic radiology facilities x A pathology laboratory x An organized medical staff of licensed doctors

For pregnancy and childbirth services the definition of ldquohospitalrdquo includes any birthing center that has a participation agreement with either Empire or another Blue Cross andor Blue Shield plan

For physical therapy purposes the definition of a ldquohospitalrdquo may include a rehabilitation facility either approved by Empire or participating with Empire or another Blue Cross andor Blue Shield plan other than specified above

For kidney dialysis treatment a facility in New York State qualifies for in-network benefits if the facility has an operating certificate issued by the New York State Department of Health and participates with Empire or another Blue Cross andor Blue Shield plan In other states the facility must participate with another Blue Cross andor Blue Shield plan and be certified by the state using criteria similar to New Yorkrsquos Out-of-network benefits will be paid only for non-participating facilities that have an appropriate operating certificate For behavioral healthcare purposes the definition of ldquohospitalrdquo may include a facility that has an operating certificate issued by the Commissioner of Mental Health under Article 31 of the New York Mental Hygiene Law a facility operated by the Office of Mental Health or a facility that has a participation agreement with Empire to provide mental and behavioral healthcare

wwwempirebluecom 67

services For alcohol andor substance abuse received out-of-network a facility in New York State must be certified by the Office of Alcoholism and Substance Abuse Services A facility outside of New York State must be approved by the Joint Commission on the Accreditation of Healthcare Organizations For certain specified benefits the definition of a ldquohospitalrdquo or ldquofacilityrdquo may include a hospital hospital department or facility that has a special agreement with Empire Empire does not recognize the following facilities as hospitals nursing or convalescent homes and institutions rehabilitation facilities (except as noted above) institutions primarily for rest or for the aged spas sanitariums infirmaries at schools colleges or camps

In-Network Benefits Benefits for covered services delivered by in-network providers and suppliers Services provided must fall within the scope of their individual professional licenses

In-Network ProviderSupplier A doctor other professional provider or durable medical equipment home health care or home infusion supplier who

x Is in Empirersquos PPO network x Is in the PPO network of another Blue Cross andor Blue Shield plan x Has a negotiated rate arrangement with another Blue Cross andor Blue Shield plan that does not have a PPO network

Itemized Bill A bill from a provider hospital or ambulance service that gives information that Empire needs to settle your claim Provider and hospital bills will contain the patientrsquos name diagnosis and date and charge for each service performed A provider bill will also have the providerrsquos name and address and descriptions of each service while a hospital bill will have the subscriberrsquos name and address the patientrsquos date of birth and the plan holderrsquos Empire identification number Ambulance bills will include the patientrsquos full name and address date and reason for service total mileage traveled and charges

Lifetime Maximum The maximum amount of benefits your plan will pay for covered expenses over the course of your lifetime

Maximum Allowed Amount (MAA) The maximum dollar amount of reimbursement for Covered Services Please see the Maximum Allowed Amount Reimbursement for Covered Services section for additional information

Medical Necessity We Cover benefits described in this Booklet as long as the health care service procedure treatment test device Prescription Drug or supply (collectively ldquoservicerdquo) is Medically Necessary The fact that a Provider has furnished prescribed ordered recommended or approved the service does not make it Medically Necessary or mean that We have to Cover it We may base Our decision on a review of x Your medical records x Our medical policies and clinical guidelines x Medical opinions of a professional society peer review committee or other groups of Physicians x Reports in peer-reviewed medical literature x Reports and guidelines published by nationally-recognized health care organizations that include supporting scientific data x Professional standards of safety and effectiveness which are generally-recognized in the United States for diagnosis care or

treatment x The opinion of Health Care Professionals in the generally-recognized health specialty involved x The opinion of the attending Providers which have credence but do not overrule contrary opinions Services will be deemed Medically Necessary only if x They are clinically appropriate in terms of type frequency extent site and duration and considered effective for Your

illness injury or disease x They are required for the direct care and treatment or management of that condition x Your condition would be adversely affected if the services were not provided x They are provided in accordance with generally accepted standards of medical practice x They are not primarily for the convenience of You Your family or Your Provider x They are not more costly than an alternative service of sequence of services that is at least as likely to produce equivalent

therapeutic or diagnostic results x When setting or place of service is part of the review services that can be safely provided to You in a lower cost setting will

not be Medically Necessary if they are performed in a higher cost setting For example we will not provide coverage for an inpatient admission for surgery if the surgery could have been performed on an outpatient basis or infusion of a specialty

68 wwwempirebluecom

drug provided in the outpatient department of a hospital if the drug could be provided in the physicianrsquos office of the home setting

Non-Participating HospitalFacility A hospital or facility that does not have a participation agreement with Empire or another Blue Cross andor Blue Shield plan to provide services to persons covered under Empirersquos PPO contract Or a hospital or facility that does not accept negotiated rate arrangements as payment in full in a plan area without a PPO network

Operating Area Empire operates in the following 28 eastern New York State counties Albany Bronx Clinton Columbia Delaware Dutchess Essex Fulton Greene Kings Montgomery Nassau New York Orange Putnam Queens Rensselaer Richmond Rockland Saratoga Schenectady Schoharie Suffolk Sullivan Ulster Warren Washington Westchester

Out-of-Network Benefits Reimbursement for covered services provided by out-of-network providers and suppliers Out-of-network benefits are generally subject to a deductible and coinsurance and therefore have higher out-of-pocket costs

Out-of-Network Deductible and Coinsurance Out-of-network benefits for all services are paid after you meet an individual or family out-of-network deductible Once your out-of-network deductible is met you and the plan share the cost You and the plan each pay a percentage called coinsurance of Empirersquos maximum allowed amount for the out-of-network service You are responsible for any amounts not covered or which are in excess of the allowed amount You pay your out-of-network coinsurance up to an annual out-of-pocket limit Once you meet your annual out-of-network out-of-pocket limit you will not be required to pay coinsurance but you will be responsible to pay the difference between the providerrsquos actual charge and Empirersquos allowed amount This is not applied to the deductible and coinsurance amounts Refer to Your Benefits at a Glance section for your out-of-network deductible coinsurance and out-of-pocket limit amounts

Out-of-Network ProvidersSuppliers A doctor other professional provider or durable medical equipment home health care or home infusion supplier who

x Is not in Empirersquos PPO network x Is not in the PPO network of another Blue Cross andor Blue Shield plan x Does not have a negotiated rate with another Blue Cross andor Blue Shield plan

Outpatient Surgery See ldquosame-day surgeryrdquo

Participating HospitalFacility A hospital or facility that

x Is in Empirersquos PPO network x Is in the PPO network of another Blue Cross andor Blue Shield plan x Has a negotiated rate arrangement with another Blue Cross andor Blue Shield plan that does not have a PPO network

Plan Administrator The person who has certain authority concerning the health plans such as plan management including deciding questions of eligibility for participation andor the administration of plan assets Empire is not the Plan Administrator To identify your Plan Administrator contact your employer or health plan sponsor

Precertified Services Services that must be coordinated and approved by Empirersquos Medical Management or Behavioral Healthcare Management Programs to be fully covered by your plan Failure to precertify may result in a reduction or denial of benefits

Provider A hospital or facility (as defined earlier in this section) or other appropriately licensed or certified professional healthcare practitioner Empire will pay benefits only for covered services within the scope of the practitionerrsquos license For behavioral healthcare purposes ldquoproviderrdquo includes care from psychiatrists psychologists or licensed clinical social workers providing psychiatric or psychological services within the scope of their practice including the diagnosis and treatment of mental and behavioral disorders Social workers must be licensed by the New York State Education Department or a comparable organization in another state and have three years of post-degree supervised experience in psychotherapy and an additional three years of post-licensure supervised experience in psychotherapy

wwwempirebluecom 69

For maternity care purposes ldquoproviderrdquo includes a certified nurse-midwife affiliated with or practicing in conjunction with a licensed facility and whose services are provided under qualified medical direction

Same-Day Surgery Same-day ambulatory or outpatient surgery is surgery that does not require an overnight stay in a hospital

Treatment Maximums Maximum number of treatments or visits for certain conditions Maximums for in-network and out-of-network services are combined For example if the plan has a limit of 30 visits on a covered expense you would reach the limit if you had 17 visits in-network and 13 visits out-of-network

70 wwwempirebluecom

AudioHealth Library Topics Following is a list of some of our most popular health-related audiotape topics that you can listen to free of charge 24 hours a day seven days a week when you call 247 NurseLine at 1-877-TALK-2RN (825-5276) See the 360˚ Health section for more information on the 247 NurseLine and instructions on how to listen to the tapes These are our most requested audiotapes If you do not see the topic that interests you just ask one of the NurseLine nurses

Abdominal Problems 1600 Appendicitis 1451 Constipation 1618 Crohnrsquos Disease 1260 Dehydration 1452 Diarrhea 1605 Diverticulosis and Diverticulitis 1402 Food Poisoning 1608 Gallbladder Disease 2154 Gallbladder Surgery 1612 Gastroesophageal Reflux Disease 1610 Heartburn 1952 Hepatitis 1403 Hernia 1603 Inflammatory Bowel Disease 1611 Irritable Bowel Syndrome 2576 Kidney Stones 1462 Nausea and Vomiting 1609 Rectal Problems 1613 Ulcers 2257 Urinary Incontinence in Women 1291 Urinary Tract Infections

Allergies 1000 Allergies 2770 Drug Allergies 1002 Food Allergies 1007 What About Allergy Shots

Back and Neck Pain 1450 Low Back Pain 1463 Herniated Disk 2174 Low Back Problems Surgery for 1457 Neck Pain

Bone Muscle and Joint Problems 1030 Arthritis 1780 Bunions 2103 Bursitis and Tendon Injury 1781 Calluses and Corns 2104 Carpal Tunnel Syndrome 1038 Fibromyalgia 1039 Gout 1784 Heel Spurs 1031 Juvenile Rheumatoid Arthritis 1033 Lupus

2106 Muscle Cramps and Leg Pain 2259 Osteoarthritis 1032 Osteoporosis 1034 Rheumatoid Arthritis 2169 Rotator Cuff 1456 Sports Injuries 2105 Strains Sprains Fractures and Dislocations 2151 Surgery for Carpal Tunnel Syndrome 1461 TM Disorder

Cancer 1105 Cancer Pain 1110 Colon Polyps 1113 Colorectal Cancer 1120 Womenrsquos Cancer 1124 Lung Cancer

Chest Respiratory and Circulatory Problems 1981 Asthma in Teens and Adults 1908 Atrial Fibrillation (irregular heartbeats) 1983 Bronchitis 1915 Cardiac Rehabilitation 1903 Causes of Heart Attack 1900 Chest Pain 1976 Chronic Obstructive Pulmonary Disease (COPD) 1400 Colds 1907 Heart Failure 1980 Emphysema 1455 Fever 1904 Heart Attack Prevention 1401 Influenza (Flu) 1648 Laryngitis 1910 Mitral Valve Prolapse 1911 Pacemakers 1986 Pneumonia 1406 Sinusitis 1459 Sore Throat and Strep Throat 1081 Stroke Rehabilitation 1460 Swollen Lymph Nodes 1912 Varicose Veins 1407 Viral and Bacterial Infection

wwwempirebluecom 71

Chronic Conditions 1060 ALS (Lou Gehrigrsquos Disease) 1061 Alzheimerrsquos Disease 1950 Chronic Fatigue Syndrome 2570 Chronic Kidney Disease 1063 Epilepsy 1953 Hepatitis B 1909 High Blood Pressure 1832 High Cholesterol 2623 Iron Deficiency Anemia 1959 Living with HIV Infection 1065 Multiple Sclerosis 1066 Parkinsonrsquos Disease 1512 Prediabetes 2550 Thyroid Problems 1508 Type 1 Diabetes 1500 Type 2 Diabetes 1501 Type 2 Diabetes Living with Complications 1502 Type 2 Diabetes Living with the Disease 1503 Type 2 Diabetes Recently Diagnosed

Ear Nose and Throat 1516 Diabetic Retinopathy 1453 Dizziness and Vertigo 1264 Ear Infections 1640 Earwax 1646 Hearing Loss 1641 Inner Ear Infection (Labrynthitis) 1644 Menierersquos Disease 1643 Swimmerrsquos Ear 1650 Tonsillitis

Eye Problems 1700 Eye Problems 2152 Cataract Surgery 1709 Cataracts 1710 Color Blindness 1703 Contact Lens Care 1708 Eye Infections 1705 Eye Injuries 1717 Floaters and Flashes 1712 Glaucoma 1711 Macular Degeneration 1716 Laser Surgery for Nearsightedness 1713 Strabismus 1707 Styes 1702 Vision Tests

First Aid and Emergencies 1750 Animal and Human Bites 1761 Burns 1255 Choking 1762 Cuts 2337 Frostbite 1901 Heart Attack 1759 Heat Exhaustion and Heat Stroke 2256 Hypothermia 2203 Importance of CPR Instructions 1751 Insect and Spider Bites and Stings 1458 Nosebleeds 1763 Poisoning 1764 Puncture Wounds 1766 Removing Splinters 1752 Snake Bites 1067 Stroke 1754 Tick Bites

Headaches and Nervous System Problems 1062 Bellrsquos Palsy 1515 Diabetic Neuropathy 1068 Guillain-Barre Syndrome 1064 Encephalitis 1405 Migraine Headaches 1404 Tension Headaches

Home Health Medicines and Supplies 2000 Bulking Agents and Laxatives 2007 Cold and Allergy Remedies 2003 Cough Preparations 2002 Decongestants 1270 How to Take a Temperature 2001 Pain Relievers 1758 Self-Care Supplies

Infant and Child Health 1250 ADHD 1251 Bed-wetting 2753 Bottle-feeding 1254 Chickenpox 1278 Childhood Rashes 1256 Circumcision 1257 Colic 1258 Croup 1261 Diaper Rash

72 wwwempirebluecom

Infant and Child Health

1080 Dyslexia 2436 Fetal Alcohol Syndrome 1253 Fever Age 3 and Younger 1267 Fifth Disease 1268 Growth and Development of the Newborn 1269 Hand-Foot-Mouth Disease 1837 Healthy Eating for Children 1272 Impetigo 1274 Measles 1275 Mumps 1280 Pinworms 1259 Reyersquos Syndrome 1283 Roseola

Medical Tests and Procedures 1506 Home Blood Sugar Monitoring 1532 Exercise Electrocardiography 1533 Complete Blood Count (CBC) 1534 Chest X-ray 1535 Chorionic Villus Sampling 1536 CT Scan of the Body 1537 Electroencephalogram 1538 Electrocardiogram 1539 Electromyography (EMG) 1540 Barium Enema 1541 Upper Gastrointestinal (GI) Series 1542 Magnetic Resonance Imaging 1546 Lung Function Tests

1284 Rubella (German Measles) 1287 Sudden Infant Death Syndrome (SIDS) 1288 Teething 1247 Temper Tantrums 1292 Thrush 1289 Thumb-Sucking 1290 Toilet Training 1293 Urinary Tract Infections in Children

Infectious Diseases 1408 Avian Influenza (Bird Flu) 1951 Infectious Mononucleosis 1956 Tuberculosis 1965 West Nile Virus

Living Healthy 1279 Immunizations 1295 Health Screenings 1830 Living a Balanced Lifestyle 1831 Guidelines for Eating Well 1833 Be Physically Active 1834 Healthy Weight 1835 Mind-Body Connection 1838 Alcohol and Drug Problems 1841 Be Tobacco-Free 1846 Managing Stress 1853 Healthy Snacks 1964 Relaxation Skills 2204 Accident and Injury Prevention 2428 Treatment for Alcohol Use Problems 2435 Teen Alcohol and Drug Abuse

1547 Abdominal Ultrasound 2155 Cystoscopy 2156 Dilation and Curettage 2157 Episiotomy 2158 Surgery for Hemorrhoids 2159 Hernia Surgery 2160 Hip Replacement Surgery 2162 Arthroscopy 2163 Knee Replacement Surgery 2164 Laparoscopy 2165 Ear Tubes 2171 Tonsillectomy and Adenoidectomy 2503 Shared Decisions about Surgery

Menrsquos Health 1128 Prostate Cancer 1545 Prostate-Specific Antigen Test (PSA Test) 2031 Hair Loss 2034 Benign Prostatic Hyperplasia (Enlarged Prostate) 2036 Testicular Problems 2167 TURP for BPH

wwwempirebluecom 73

Mental Health Problems and Mind-Body Wellness 1069 Bipolar Disorder 1070 Schizophrenia 1071 Dementia 1230 Domestic Violence 1240 Child Maltreatment 1845 Stress Management 2051 Obsessive-compulsive Disorder 2052 Eating Disorders 2055 Panic Attacks and Panic Disorder 2057 Depression 2059 Grief 2063 Social Anxiety Disorder 2066 Suicide

Partnership with your doctor 1201 Patients Bill of Rights 1202 Caregiver Secrets 1800 Skills for Making Wise Health Decisions 1801 Work in Partnership with your Doctor 1802 Finding a Doctor Who Will be a Partner

2352 Sunburn 2353 Warts

Sleeping Disorders 2400 Sleep Problems 2403 Sleep Apnea 2406 Snoring

Womenrsquos Health 1107 Breast Health 1111 Ovarian Cancer 1112 Polycystic Ovary Syndrome 1211 Multiple Pregnancy Twins or More 1504 Gestational Diabetes 1531 Breast Biopsy 1544 Pelvic Exam and Pap Test 1548 Ultrasound for Normal Pregnancy 2312 Pelvic Inflammatory Disease 2426 Pregnancy Precautions During 2640 Bacterial Vaginosis 2643 Yeast Infections 2650 Menopause

Senior Health 1836 Seniors Staying Active and Fit 2004 Medication Problems in Seniors 2006 Medications and Older Adults 2240 Hospice Care 2245 Care at the End of Life 2251 Nutrition for Older Adults 2261 Skin and Nail Problems in Seniors

Skin Problems 1129 Skin Cancer 1273 Lice and Scabies 1755 Blisters 1785 Ingrown Toenails 2330 Acne 2332 Boils 2333 Cold Sores 2334 Dandruff 2336 Atopic Dermatitis 2338 Hives 2343 Rashes 2344 Psoriasis 2346 Fungal Infections 2349 Shingles

2651 Hormone Therapy 2670 Missed or Irregular Periods 2672 Endometriosis 2673 Uterine Fibroids 2674 Hysterectomy 2675 Bleeding Between Periods 2677 Functional Ovarian Cysts 2678 Menstrual Cramps 2679 Dsyfuntional Uterine Bleeding 2680 Toxic Shock Syndrome 2700 How to Make a Healthy Baby 2701 Home Pregnancy Test 2704 Danger signs during pregnancy 2705 Normal Pregnancy 2706 Symptoms and Stages of Labor 2708 Diet During Pregnancy 2709 Exercise During Pregnancy 2710 Rubella and Pregnancy 2714 Amniocentesis 2717 Miscarriage 2719 Stretch Marks 2720 Cesarean Section 2723 Pelvic Organ Prolaps 2724 Premenstrual Syndrome

74 wwwempirebluecom

Womenrsquos Health 2725 Pregnancy Symptoms and Stages of 2750 Postpartum Depression 2751 Breast Feeding 2752 Complications after delivery 2754 Labor Delivery and Postpartum Period 2755 Mastitis While Breast-Feeding 2756 Rh Sensitization During Pregnancy 2757 Weaning

Additional topics that are not listed are also available

wwwempirebluecom 75

2016 AMENDMENT This Amendment changes provisions in or adds provisions to your Benefit Booklet including any affected riders endorsements or other amendments thereto issued by Empire upon your Planrsquos renewal on or after January 1 2016 Except as otherwise provided for in this Amendment the provisions herein apply to all persons covered under the Benefit Booklet (ldquoMembersrdquo) All of the terms conditions and limitations of the Benefit Booklet to which this Amendment is attached also apply to this Amendment except where they are specifically changed by this Amendment A References to ldquo360deg Healthreg Empirersquos Health Services Programsrdquo are changed to ldquoHealth and

Wellness Solutionsrdquo B The following is added to the Assignment of Benefits provision

Any purported assignment of benefits shall be void Any purported assignee of benefits shall acquire no rights by reason of any such purported assignment

C The following revisions apply to your Ambulatory Surgery benefit

a References to Ambulatory Surgery are hereby deleted and replaced with the following term

Same Day surgery Same-day or outpatient surgery is surgery performed in a hospital or other facility that does not require an overnight stay For same-day surgery the definition of ldquohospitalrdquo may include a free-standing ambulatory surgical facility that has a participation agreement with either Empire or another Blue Cross andor Blue Shield plan ldquoFacilityrdquo does not include a providerrsquos office

b i The following provision is deleted from your Benefit Booklet

You are also covered for same-day (outpatient or ambulatory) hospital services such as chemotherapy radiation therapy cardiac rehabilitation and kidney dialysis Same-day surgical services or invasive diagnostic procedures are covered when they

x Are performed in a same day or hospital outpatient surgical facility x Require the use of both surgical operating and postoperative recovery rooms x May require either local or general anesthesia x Do not require inpatient hospital admission because it is not appropriate or medically

necessary and x Would justify an inpatient hospital admission in the absence of a same-day surgery program

ii The following provision is added to your Benefit Booklet You are also covered for same-day (outpatient or ambulatory) hospital services such as chemotherapy radiation therapy cardiac rehabilitation and kidney dialysis Same-day surgical services or invasive diagnostic procedures are covered when they

x Are performed in a hospital outpatient facility x Require the use of both surgical operating and postoperative recovery rooms x May require either local or general anesthesia x Do not require inpatient hospital admission because it is not appropriate or medically

necessary and x Would justify an inpatient hospital admission in the absence of a same-day surgery program

D The following defined terms are added to your Benefit Booklet a Health Care Professional An appropriately licensed registered or certified Physician

dentist optometrist chiropractor psychologist social worker podiatrist physical therapist occupational therapist midwife speech-language pathologist audiologist pharmacist behavior analyst or any other licensed registered or certified Health Care Professional under Title 8 of the New York Education Law (or other comparable state law if applicable) that the New York Insurance Law requires to be recognized who

76 wwwempirebluecom

charges and bills patients for Covered Services The Health Care Professionalrsquos services must be rendered within the lawful scope of practice for that type of Provider in order to be covered under this benefit plan

b Provider A Physician Health Care Professional or Facility licensed registered certified or accredited as required by law A Provider also includes a vendor or dispenser of diabetic equipment and supplies durable medical equipment medical supplies or any other equipment or supplies that are Covered under this benefit plan that is licensed registered certified or accredited as required by law

wwwempirebluecom 77

2017 AMENDMENT

This Amendment changes provisions in or adds provisions to your Benefit Booklet including any affected riders endorsements or other amendments thereto issued by Empire upon your Planrsquos renewal on or after January 1 2017 Except as otherwise provided for in this Amendment the provisions herein apply to all persons covered under the Benefit Booklet (ldquoMembersrdquo) All of the terms conditions and limitations of the Benefit Booklet to which this Amendment is attached also apply to this Amendment except where they are specifically changed by this Amendment

A The following is added to the Introduction section of your Benefit Booklet Your Employer has agreed to be subject to the terms and conditions of Empirersquos provider agreements which may include precertification and utilization management requirements timely filing limits and other requirements to administer the benefits under this Plan

B The BlueCard andor Inter-Plan Program provision language is hereby deleted and

replaced with the following Inter-Plan Programs

1 Out-of-Area Services We have a variety of relationships with other Blue Cross andor Blue Shield Licensees

Generally these relationships are called ldquoInter-Plan Arrangementsrdquo These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross Blue Shield Association (ldquoAssociationrdquo) Whenever You access healthcare services outside the geographic area We serve (the ldquoEmpire Service Areardquo) the claim for those services may be processed through one of these Inter-Plan Arrangements The Inter-Plan Arrangements are described below When You receive care outside of the Empire Service Area You will receive it from one of two kinds of Providers Most Providers (ldquoParticipating Providersrdquo) contract with the local Blue Cross andor Blue Shield Plan in that geographic area (ldquoHost Bluerdquo) Some Providers (ldquoNon-Participating Providersrdquo) donrsquot contract with the Host Blue We explain below how We pay both kinds of Providers Inter-Plan Arrangements Eligibility ndash Claim Types Most claim types are eligible to be processed through Inter-Plan Arrangements as described above Examples of claims that are not included are prescription drugs that You obtain from a pharmacy and most dental or vision benefits

2 BlueCardreg Program Under the BlueCardreg Program when You receive Covered Services within the geographic area served by a Host Blue We will still fulfill Our contractual obligations But the Host Blue is responsible for (a) contracting with its Providers and (b) handling its interactions with those Providers When You receive Covered Services outside the Empire Service Area and the claim is processed through the BlueCard Program the amount You pay is calculated based on the lower of

x The billed charges for Covered Services or x The negotiated price that the Host Blue makes available to Us

Often this ldquonegotiated pricerdquo will be a simple discount that reflects an actual price that the Host Blue pays to the Provider Sometimes it is an estimated price that takes into account special arrangements with that Provider Sometimes such an arrangement may be an average price based on a discount that results in expected average savings for services provided by similar types of Providers Estimated and average pricing arrangements may also involve types of settlements incentive payments andor other credits or charges Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims as noted above However such adjustments will not affect the price We used for Your claim because they will not be applied after a claim has already been paid

3 Special Cases Value-Based Programs BlueCardreg Program If You receive Covered Services under a value-based program inside a Host Bluersquos service area You will not be responsible for paying any of the Provider Incentives risk-sharing andor Care Coordinator Fees that are a part of such an arrangement except when a Host Blue passes these fees to Empire through average pricing or fee schedule adjustments Additional information is available upon request

78 wwwempirebluecom

4 Inter-Plan Programs FederalState TaxesSurchargesFees Federal or state laws or regulations may require

a surcharge tax or other fee If applicable We will include any such surcharge tax or other fee as part of the claim charge passed on to You

5 Non-Participating Providers Outside Our Service Area a Allowed Amounts and Member Liability Calculation When Covered Services are provided outside of

Empirersquos Service Area by Non-Participating Providers We may determine benefits and make payment based on pricing from either the Host Blue or the pricing arrangements required by applicable state or federal law In these situations the amount You pay for such services as Deductible Copayment or Coinsurance will be based on that allowed amount Also You may be responsible for the difference between the amount that the Non-Participating Provider bills and the payment We will make for the Covered Services as set forth in this paragraph Federal or state law as applicable will govern payments for out-of-network emergency services

b Exceptions In certain situations We may use other pricing methods such as billed charges the pricing We would use if the healthcare services had been obtained within the Empire Service Area or a special negotiated price to determine the amount We will pay for services provided by Non-Participating Providers In these situations You may be liable for the difference between the amount that the Non-Participating Provider bills and the payment We make for the Covered Services as set forth in this paragraph

6 BlueCard Worldwidereg Program If You plan to travel outside the United States call Member Services to

find out Your BlueCard Worldwide benefits Benefits for services received outside of the United States may be different from services received in the United States Remember to take an up to date health ID card with You When You are traveling abroad and need medical care You can call the BlueCard Worldwide Service Center any time They are available 24 hours a day seven (7) days a week The toll free number is 800-810-2583 Or You can call them collect at 804-673-1177 If You need inpatient hospital care You or someone on Your behalf should contact Us for preauthorization Keep in mind if You need emergency medical care go to the nearest hospital There is no need to call before You receive care How claims are paid with BlueCard Worldwide In most cases when You arrange inpatient hospital care with BlueCard Worldwide claims will be filed for You The only amounts that You may need to pay up front are any Copayment Coinsurance or Deductible amounts that may apply You will typically need to pay for the following services up front

x Doctors services x Inpatient hospital care not arranged through BlueCard Worldwide and x Outpatient services

You will need to file a claim form for any payments made up front

When You need BlueCard Worldwide claim forms You can get international claim forms in the following ways

x Call the BlueCard Worldwide Service Center at the numbers above or x Online at wwwbluecardworldwidecom

You will find the address for mailing the claim on the form

C The Subrogation and Reimbursement provisions are hereby deleted and replaced with the following

Subrogation and Reimbursement These provisions apply when the Plan pays benefits as a result of injuries or illnesses you sustained and you have a right to a Recovery or have received a Recovery from any source A ldquoRecoveryrdquo includes but is not limited to monies received from any person or party any personrsquos or partyrsquos liability insurance uninsuredunderinsured motorist proceeds workerrsquos compensation insurance or fund ldquono-faultrdquo insurance andor automobile medical payments coverage whether by lawsuit settlement or otherwise Regardless of how

wwwempirebluecom 79

you or your representative or any agreements characterize the money you receive as a Recovery it shall be subject to these provisions 1 Subrogation

The Plan has the right to recover payments it makes on your behalf from any party responsible for compensating you for your illnesses or injuries The following apply The Plan has first priority from any Recovery for the full amount of benefits it has paid regardless of whether you are fully compensated and regardless of whether the payments you receive make you whole for your losses illnesses andor injuries You and your legal representative must do whatever is necessary to enable the Plan to exercise the Plans rights and do nothing to prejudice those rights In the event that you or your legal representative fails to do whatever is necessary to enable the Plan to exercise its subrogation rights the Plan shall be entitled to deduct the amount the Plan paid from any future benefits under the Plan The Plan has the right to take whatever legal action it sees fit against any person party or entity to recover the benefits paid under the Plan To the extent that the total assets from which a Recovery is available are insufficient to satisfy in full the Plans subrogation claim and any claim held by you the Plans subrogation claim shall be first satisfied before any part of a Recovery is applied to your claim your attorney fees other expenses or costs The Plan is not responsible for any attorney fees attorney liens other expenses or costs you incur The common fund doctrine does not apply to any funds recovered by any attorney you hire regardless of whether funds recovered are used to repay benefits paid by the Plan

2 Reimbursement

If you obtain a Recovery and the Plan has not been repaid for the benefits the Plan paid on your behalf the Plan shall have a right to be repaid from the Recovery in the amount of the benefits paid on your behalf and the following provisions will apply You must promptly reimburse the Plan from any Recovery to the extent of benefits the Plan paid on your behalf regardless of whether the payments you receive make you whole for your losses illnesses andor injuries Notwithstanding any allocation or designation of your Recovery (eg pain and suffering) made in a settlement agreement or court order the Plan shall have a right of full recovery in first priority against any Recovery Further the Planrsquos rights will not be reduced due to your negligence You and your legal representative must hold in trust for the Plan the proceeds of the gross Recovery (ie the total amount of your Recovery before attorney fees other expenses or costs) to be paid to the Plan immediately upon your receipt of the Recovery You and your legal representative acknowledge that the portion of the Recovery to which the Planrsquos equitable lien applies is a Plan asset Any Recovery you obtain must not be dissipated or disbursed until such time as the Plan has been repaid in accordance with these provisions You must reimburse the Plan in first priority and without any set-off or reduction for attorney fees other expenses or costs The common fund doctrine does not apply to any funds recovered by any attorney you hire regardless of whether funds recovered are used to repay benefits paid by the Plan If you fail to repay the Plan the Plan shall be entitled to deduct any of the unsatisfied portion of the amount of benefits the Plan has paid or the amount of your Recovery whichever is less from any future benefit under the Plan if The amount the Plan paid on your behalf is not repaid or otherwise recovered by the Plan or You fail to cooperate

80 wwwempirebluecom

In the event that you fail to disclose the amount of your settlement to the Plan the Plan shall be entitled to deduct the amount of the Planrsquos lien from any future benefit under the Plan The Plan shall also be entitled to recover any of the unsatisfied portion of the amount the Plan has paid or the amount of your Recovery whichever is less directly from the Providers to whom the Plan has made payments on your behalf In such a circumstance it may then be your obligation to pay the Provider the full billed amount and the Plan will not have any obligation to pay the Provider or reimburse you The Plan is entitled to reimbursement from any Recovery in first priority even if the Recovery does not fully satisfy the judgment settlement or underlying claim for damages or fully compensate you or make you whole

3 Your Duties

You must promptly notify the Plan of how when and where an accident or incident resulting in personal injury or illness to you occurred all information regarding the parties involved and any other information requested by the Plan You must cooperate with the Plan in the investigation settlement and protection of the Plans rights In the event that you or your legal representative fails to do whatever is necessary to enable the Plan to exercise its subrogation or reimbursement rights the Plan shall be entitled to deduct the amount the Plan paid from any future benefits under the Plan You must not do anything to prejudice the Plans rights You must send the Plan copies of all police reports notices or other papers received in connection with the accident or incident resulting in personal injury or illness to you You must promptly notify the Plan if you retain an attorney or if a lawsuit is filed on your behalf You must immediately notify the Plan if a trial is commenced if a settlement occurs or if potentially dispositive motions are filed in a case The Plan Sponsor has sole discretion to interpret the terms of the Subrogation and Reimbursement provision of this Plan in its entirety and reserves the right to make changes as it deems necessary If the covered person is a minor any amount recovered by the minor the minorrsquos trustee guardian parent or other representative shall be subject to this provision Likewise if the covered personrsquos relatives heirs andor assignees make any Recovery because of injuries sustained by the covered person that Recovery shall be subject to this provision The Plan is entitled to recover its attorneyrsquos fees and costs incurred in enforcing this provision The Plan shall be secondary in coverage to any medical payments provision no-fault automobile insurance policy or personal injury protection policy regardless of any election made by you to the contrary The Plan shall also be secondary to any excess insurance policy including but not limited to school andor athletic policies

D Provision language related to Special Enrollment Periods is hereby deleted and replaced

with the following

You Your Spouse or Child can also enroll for coverage within 60 days of the loss of coverage in another group health plan if coverage was terminated because You Your Spouse or Child are no longer eligible for coverage under the other group health plan due to

1 Termination of employment 2 Termination of the other group health plan 3 Death of the Spouse 4 Legal separation divorce or annulment 5 Reduction of hours of employment

wwwempirebluecom 81

6 Employer contributions toward the group health plan were terminated for You or Your Dependentsrsquo coverage or

7 A Child no longer qualifies for coverage as a Child under the other group health plan You Your Spouse or Child can also enroll 60 days from exhaustion of Your COBRA or continuation coverage or if You gain a Dependent or become a Dependent through marriage birth adoption or placement for adoption We must receive notice within 60 days of the loss of coverage The effective date of Your coverage will be the date indicated on the application In addition You Your Spouse or Child can also enroll for coverage within 60 days of the occurrence of one of the following events

1 You or Your Spouse or Child loses eligibility for Medicaid or a state child health plan or 2 You or Your Spouse or Child becomes eligible for Medicaid or a state child health plan

We must receive notice within 60 days of one of these events The effective date of Your coverage will be the date indicated on the application

E The following is added to the Exclusions and Limitations section of Your Benefit Booklet

x Conversion Therapy We do not cover conversion therapy Conversion therapy is any practice by a mental

health professional that seeks to change the sexual orientation or gender identity of a Member under 18 years of age including efforts to change behaviors gender expressions or to eliminate or reduce sexual or romantic attractions or feelings toward individuals of the same sex Conversion therapy does not include counseling or therapy for an individual who is seeking to undergo a gender transition or who is in the process of undergoing a gender transition that provides acceptance support and understanding of an individual or the facilitation of an individualrsquos coping social support and identity exploration and development including sexual orientation-neutral interventions to prevent or address unlawful conduct or unsafe sexual practices provided that the counseling or therapy does not seek to change sexual orientation or gender identity

82 wwwempirebluecom

2018 AMENDMENT

This Amendment changes provisions in or adds provisions to your Benefit Booklet including any affected riders endorsements or other amendments thereto issued by Empire upon your Planrsquos renewal on or after January 1 2018 Except as otherwise provided for in this Amendment the provisions herein apply to all persons covered under the Benefit Booklet (ldquoMembersrdquo) All of the terms conditions and limitations of the Benefit Booklet to which this Amendment is attached also apply to this Amendment except where they are specifically changed by this Amendment

A The following is added to the listing of services requiring prior authorization or precertification x Genetic Testing

B The BlueCard andor Inter-Plan Program provision language is hereby deleted and replaced with

the following Inter-Plan Programs 1 Out-of-Area Services We have a variety of relationships with other Blue Cross andor Blue

Shield Licensees Generally these relationships are called ldquoInter-Plan Arrangementsrdquo These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross Blue Shield Association (rdquoAssociationrdquo) Whenever You access healthcare services outside of the geographic area We serve (the ldquoEmpire Service Areardquo) the claims for these services may be processed through one of these Inter-Plan Arrangements The Inter-Plan Arrangements are described below

When You receive care outside of the Empire Service Area You will receive it from one of two kinds of Providers Most Providers (ldquoParticipating Providersrdquo) contract with the local Blue Cross andor Blue Shield Plan in that geographic area (ldquoHost Bluerdquo) Some Providers (ldquoNon-Participating Providersrdquo) donrsquot contract with the Host Blue We explain below how We pay both kinds of Providers

Inter-Plan Arrangements Eligibility ndash Claim Types Most claim types are eligible to be processed through Inter-Plan Arrangements as described above Examples of claims that are not included are prescription drugs that You obtain from a pharmacy and most dental or vision benefits

2 BlueCardreg Program Under the BlueCardreg Program when You receive Covered Services within the geographic area served by a Host Blue We will still fulfill Our contractual obligations But the Host Blue is responsible for (a) contracting with its Providers and (b) handling its interactions with those Providers

When You receive Covered Services outside the Empire Service Area and the claim is processed through the BlueCard Program the amount You pay is calculated based on the lower of

x The billed charges for Covered Services or x The negotiated price that the Host Blue makes available to Us

Often this ldquonegotiated pricerdquo will be a simple discount that reflects an actual price that the Host Blue pays to the Provider Sometimes it is an estimated price that takes into account special arrangements with that Provider Sometimes such an arrangement may be an average price based on a discount that results in expected average savings for services provided by similar types of Providers Estimated and average pricing arrangements may also involve types of settlements incentive payments andor other credits or charges Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims as noted above However such adjustments will not affect the price We used for Your claim because they will not be applied after a claim has already been paid

3 Special Cases Value-Based Programs BlueCardreg Program If You receive Covered Services under a value-based program inside a Host Bluersquos service area You will not be responsible for paying any of the Provider Incentives risk-sharing andor Care Coordinator Fees that are a part

wwwempirebluecom 83

of such an arrangement except when a Host Blue passes these fees to Empire through average pricing or fee schedule adjustments

4 Inter-Plan Programs FederalState TaxesSurchargesFees Federal or state laws or regulations may require a surcharge tax or other fee If applicable We will include any such surcharge tax or other fee as part of the claim charge passed on to You

5 Non-Participating Providers Outside Our Service Area

a Allowed Amounts and Member Liability Calculation When Covered Services are provided outside of Empirersquos Service Area by non-participating providers We may determine benefits and make payment based on pricing from either the Host Blue or the pricing arrangements required by applicable state or federal law In these situations the amount You pay for such services as Deductible Copayment or Coinsurance will be based on that allowed amount Also You may be responsible for the difference between the amount that the non-participating provider bills and the payment We will make for the Covered Services as set forth in this paragraph Federal or state law as applicable will govern payments for out-of-network emergency services

b Exceptions In certain situations We may use other pricing methods such as billed charges the pricing We would use if the healthcare services had been obtained within the Empire Service Area or a special negotiated price to determine the amount We will pay for services provided by non-participating providers In these situations You may be liable for the difference between the amount that the non-participating provider bills and the payment We make for the Covered Services as set forth in this paragraph

6 Blue Cross Blue Shield Global Corereg Program If You plan to travel outside the United States

call Member Services to find out Your Blue Cross Blue Shield Global Corereg benefits Benefits for services received outside of the United States may be different from services received in the United States The plan only covers Emergency including ambulance and Urgent Care outside of the United States Remember to take an up to date health ID card with You

When You are traveling abroad and need medical care You can call the Blue Cross Blue Shield Global Corereg Service Center any time They are available 24 hours a day seven (7) days a week The toll free number is 800-810-2583 Or You can call them collect at 804-673-1177

How claims are paid with Blue Cross Blue Shield Global Corereg In most cases when You arrange inpatient hospital care with Blue Cross Blue Shield Global Corereg claims will be filed for You The only amounts that You may need to pay up front are any Copayment Coinsurance or Deductible amounts that may apply You will typically need to pay for the following services up front x Doctors services x Inpatient hospital care not arranged through Blue Cross Blue Shield Global Corereg and x Outpatient services

You will need to file a claim form for any payments made up front

When You need Blue Cross Blue Shield Global Corereg claim forms You can get international claim forms in the following ways x Call the Blue Cross Blue Shield Global Corereg Service Center at the numbers above or x Online atwwwbcbsglobalcorecom

You will find the address for mailing the claim on the form

C The ldquoInitial Decisionsrdquo section of the ldquoHealth Managementrdquo chapter of your benefit booklet is hereby deleted and replaced with the following 5 Preauthorization Reviews

d Non-Urgent Preauthorization Reviews If We have all the information necessary to make a determination regarding a Preauthorization review We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of

84 wwwempirebluecom

receipt of the request

If We need additional information We will request it within fifteen (15) calendar days You or Your Provider will then have 45 calendar days to submit the information If We receive the requested information within 45 days We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of Our receipt of the additional information If all necessary information is not received within 45 days We will make a determination within 15 calendar days of the end of the 45 day period allowed to submit the additional information

e Urgent Preauthorization Reviews With respect to urgent Preauthorization requests if We

have all information necessary to make a determination We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within 72 hours of receipt of the request If We need additional information We will request it within 24 hours You or Your Provider will then have 48 hours to submit the information We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within 48 hours of the earlier of Our receipt of the additional information or the end of the 48-hour period allowed to submit additional information

f Court Ordered Treatment With respect to requests for mental health andor substance use

disorder services that have not yet been provided if You (or Your designee) certify in a format prescribed by the Superintendent of Financial Services that You will be appearing or have appeared before a court of competent jurisdiction and may be subject to a court order requiring such services We will make a determination and provide notice to You (or Your designee) and Your Provider by telephone within 72 hours of receipt of the request Written notification will be provided within three (3) business days of Our receipt of the request Where feasible the telephonic and written notification will also be provided to the court

6 Concurrent Reviews

4 Non-Urgent Concurrent Reviews Utilization Review decisions for services during the course of care (concurrent reviews) will be made and notice provided to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of receipt of all necessary information If We need additional information We will request it within fifteen (15) calendar days of the receipt of the request You or Your Provider will then have 45 calendar days to submit the additional information We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of Our receipt of the additional information or if We do not receive the information within 15 calendar days of the end of the 45-day period allowed to provide the additional information

5 Urgent Concurrent Reviews For concurrent reviews that involve an extension of urgent care if

the request for coverage is made at least 24 hours prior to the expiration of a previously approved treatment We will make a determination and provide notice to You (or Your designee) and Your Provider within 24 hours of receipt of the request If the request for coverage is not made at least 24 hours prior to the expiration of a previously approved treatment We will make a determination and provide written notice to You (or Your designee) and Your Provider within 72 hours of receipt of the request If We need additional information We will request it within 24 hours You or Your Provider will then have 48 hours to submit the information We will make a determination and provide written notice to You (or Your designee) and Your Provider within the earlier of one (1) business day or 48 hours of Our receipt of the information or if We do not receive the information within 48 hours of the end of the 48-hour period

6 Inpatient Substance Use Disorder Treatment Reviews If a request for inpatient substance use disorder treatment is submitted to Us at least 24 hours prior to discharge from an inpatient substance use disorder treatment admission We will make a determination within 24 hours of receipt of the request and We will provide coverage for the inpatient substance use disorder treatment while Our determination is pending

wwwempirebluecom 85

7 Retrospective Reviews If We have all information necessary to make a determination regarding a

retrospective claim We will make a determination and notify You and Your Provider within 30 calendar days of the receipt of the request If We need additional information We will request it within 30 calendar days You or Your Provider will then have 45 calendar days to provide the information We will make a determination and provide notice to You and Your Provider in writing within 15 calendar days of the earlier of Our receipt of the information or the end of the 45-day period

Once We have all the information to make a decision Our failure to make a Utilization Review determination within the applicable time frames set forth above will be deemed an adverse determination subject to an internal Appeal

8 Retrospective Review of Preauthorized Services We may only reverse a preauthorized treatment

service or procedure on retrospective review when x The relevant medical information presented to Us upon retrospective review is materially

different from the information presented during the Preauthorization review x The relevant medical information presented to Us upon retrospective review existed at the

time of the Preauthorization but was withheld or not made available to Us x We were not aware of the existence of such information at the time of the Preauthorization

review and x Had We been aware of such information the treatment service or procedure being

requested would not have been authorized The determination is made using the same specific standards criteria or procedures as used during the Preauthorization review

D Coverage for Online Visits is revised as follows

x Online visits Your coverage includes online physician office visits Covered Services

include a visit with the physician using the internet via a webcam with online chat or voice functions Services are provided by board certified licensed Primary Care Physicians Online visits are not for specialist care Common types of diagnoses and conditions treated online are cough fever headaches sore throat routine child health issues influenza upper respiratory infections sinusitis bronchitis and urinary tract infections when uncomplicated in nature Member Access To begin the online visit log on to wwwlivehealthonlinecom and establish an online account by providing some basic information about You and Your insurance plan Before You connect to a Doctor You will be asked to identify the kind of condition You want to discuss with the Doctor list Your local pharmacy provide information for the credit card You want Your cost share for the visit to be billed to agree to the terms of use and select an available Physician If You are not in New York State when You seek an online visit You will need to check to be sure an online Doctor is available in the state You are in because online Doctors are not available in every state The visit with the Physician will not start until You provide the above information and click ldquoconnectrdquo The visit will be documented in an electronic health record You may access Your records and print them and may email or fax them to Your Primary Care Physician Note about Covered Services Online visits are not meant for the following purposes

x To get reports of normal lab or other test results x To request an office appointment x To ask billing insurance coverage or payment questions x To ask for a referral to a specialist Doctor x To request Preauthorization for a benefit under your health Plan or x To ask the Physician to consult with another Physician

E The following provisions related to Claim Determinations are added to your benefit booklet

1 Claims A claim is a request that benefits or services be provided or paid according to the terms of

this Booklet When You receive services from a Participating Provider You will not need to submit a claim form However if You receive services from a Non-Participating Provider either You or the Provider must file a claim form with Us If the Non-Participating Provider is not willing to file the claim form You will need to file it with Us See the Coordination of Benefits section of this Booklet for

86 wwwempirebluecom

information on how We coordinate benefit payments when You also have health coverage with another plan

2 Notice of Claim Claims for services must include all information designated by Us as

necessary to process the claim including but not limited to Member identification number name date of birth date of service type of service the charge for each service procedure code for the service as applicable diagnosis code name and address of the Provider making the charge and supporting medical records when necessary A claim that fails to contain all necessary information will not be accepted and must be resubmitted with all necessary information Claim forms are available from Us by calling the number on Your ID card or visiting Our website at wwwempirebluecom Completed claim forms should be sent to the address in the How Your Coverage Works section of this Booklet or on Your ID card You may also submit a claim to Us electronically by sending it to the e-mail address in the How Your Coverage Works section of this Booklet on Your ID card or visiting Our website at wwwempirebluecom

3 Timeframe for Filing Claims Claims for services must be submitted to Us for payment within 18

months after You receive the services for which payment is being requested If it is not reasonably possible to submit a claim within the 18 month period You must submit it as soon as reasonably possible

4 Claims for Prohibited Referrals We are not required to pay any claim bill or other demand or

request by a Provider for clinical laboratory services pharmacy services radiation therapy services physical therapy services or x-ray or imaging services furnished pursuant to a referral prohibited by Section 238-a(1) of the New York Public Health Law

5 Claim Determinations Our claim determination procedure applies to all claims that do not relate to

a medical necessity or experimental or investigational determination For example Our claim determination procedure applies to contractual benefit denials If You disagree with Our claim determination You may submit a Grievance pursuant to the Grievance Procedures section of this Booklet

For a description of the Utilization Review procedures and Appeal process for medical necessity or experimental or investigational determinations see the Utilization Review and External Appeal sections of this Booklet

6 Pre-Service Claim Determinations

1 A pre-service claim is a request that a service or treatment be approved before it has been received If We have all the information necessary to make a determination regarding a pre-service claim (eg a covered benefit determination) We will make a determination and provide notice to You (or Your designee) within 15 days from receipt of the claim

If We need additional information We will request it within 15 days from receipt of the claim You will have 45 calendar days to submit the information If We receive the information within 45 days We will make a determination and provide notice to You (or Your designee) in writing within 15 days of Our receipt of the information If all necessary information is not received within 45 days We will make a determination within 15 calendar days of the end of the 45 day period

2 Urgent Pre-Service Reviews With respect to urgent pre-service requests if We have all

information necessary to make a determination We will make a determination and provide notice to You (or Your designee) within 72 hours of receipt of the request If We need additional information We will request it within 24 hours of receipt of the request You will then have 48 hours to submit the information We will make a determination and provide notice to You (or Your designee) within 48 hours of the earlier of Our receipt of the additional information or if information was not received at the end of the 48-hour period allowed to submit the information

7 Post-Service Claim Determinations A post-service claim is a request for a service or treatment that

You have already received If We have all information necessary to make a determination regarding a post-service claim We will make a determination and notify You (or Your designee) within 30 calendar days of the receipt of the claim If We need additional information We will request it within 30 calendar days You will then have 45 calendar days to provide the information We will make a determination and provide notice to You (or Your designee) in writing within 15 calendar days of the

wwwempirebluecom 87

earlier of Our receipt of the information or the end of the 45 day period

F The definition of ldquoProvidersrdquo is revised as follows

x For behavioral healthcare purposes ldquoproviderrdquo includes care from licensed psychiatrists or psychologists licensed clinical social workers licensed mental health counselors licensed marriage and family therapists licensed psychoanalysts licensed psychiatric nurse licensed as a nurse practitioner or clinical nurse specialist or a professional corporation or a university faculty practice corporation thereof Social workers must be licensed by the New York State Education Department or a comparable organization in another state and have three years of post-degree supervised experience in psychotherapy and an additional three years of post-licensure supervised experience in psychotherapy

88 wwwempirebluecom

Get Help In Your Language Curious to know what all this says We would be too Herersquos the English version This notice has important information about your application or benefits Look for important dates You might need to take action by certain dates to keep your benefits or manage costs You have the right to get this information and help in your language for free Call the Member Services number on your ID card for help (TTYTDD 711) Spanish Este aviso contiene informacioacuten importante acerca de su solicitud o sus beneficios Busque fechas importantes Podriacutea ser necesario que actuacutee para ciertas fechas a fin de mantener sus beneficios o administrar sus costos Tiene el derecho de obtener esta informacioacuten y ayuda en su idioma en forma gratuita Llame al nuacutemero de Servicios para Miembros que figura en su tarjeta de identificacioacuten para obtener ayuda (TTYTDD 711) Albanian Ky njoftim peumlrmban informacion teuml reumlndeumlsisheumlm rreth aplikimit ose peumlrfitimeve tuaja Shihni datat kryesore Mund trsquoju nevojitet teuml veproni brenda afateve teuml caktuara peumlr teuml vazhduar teuml peumlrfitoni ose peumlr teuml menaxhuar kostot Keni teuml drejteumln teuml merrni falas ndihmeuml dhe informacion neuml gjuheumln tuaj Peumlr ndihmeuml telefononi numrin e sheumlrbimeve peumlr aneumltareumlt teuml sheumlnuar neuml karteumln tuaj ID (TTYTDD 711) Arabic

محددة مواعید قبل إجراء اتخاذ إلى تحتاج قد المھمة المواعید تتبع على احرص لك المقدمة المزایا أو طلبك حول مھمة معلومات على الإشعار ھذا یحتوي بطاقة على الموجود الأعضاء خدمات برقم الاتصال یرجى جانام بلغتك والمساعدة المعلومات ھذه على الحصول لك یحق التكلفة لإدارة أو بالمزایا للاحتفاظ(TTYTDD711)للمساعدة بك الخاصة التعریف

Bengali আপনার আবেদন বা সবিধার বিষয়ে এই বিজঞপতিটিতে গরতবপরণ তথয রয়েছে গরতবপরণ তারিখগলির জনয দেখন আপনার সবিধাগলি বজায় রাখার জনয বা খরচ নিয়নতরণ করার জনয নিরদিষট তারিখে আপনাকে কাজ করতে হতে পারে বিনামলযে এই তথয পাওয়ার ও আপনার ভাষায় সাহাযয করার অধিকার আপনার আছে সাহাযযের জনয আপনার আইডি কারডে থাকা সদসয পরিষেবা নমবরে কল করন (TTYTDD 711) Chinese 本通知有與您的申請或利益相關的重要資訊請留意重要日期您可能需要在特定日期前採取行動以維護您的利益

或管理費用您有權使用您的語言免費獲得該資訊和協助請撥打您的 ID

卡上的成員服務號碼尋求協助(TTYTDD 711) French Cette notice contient des informations importantes sur votre demande ou votre couverture Vous y trouverez eacutegalement des dates agrave ne pas manquer Il se peut que vous deviez respecter certains deacutelais pour conserver votre couverture santeacute ou vos remboursements Vous avez le droit drsquoacceacuteder gratuitement agrave ces informations et agrave une aide dans votre langue Pour cela veuillez appeler le numeacutero des Services destineacutes aux membres qui figure sur votre carte drsquoidentification (TTYTDD 711) Greek Αυτή η ειδοποίηση περιέχει σημαντικές πληροφορίες για την εφαρμογή σας ή τις παροχές σας Αναζητήστε τις σημαντικές ημερομηνίες Ενδέχεται να χρειαστεί να κάνετε κάποιες ενέργειες μέχρι συγκεκριμένες ημερομηνίες ώστε να διατηρήσετε τις παροχές σας ή να διαχειριστείτε το κόστος Έχετε το δικαίωμα να λάβετε αυτές τις πληροφορίες και αυτήν τη βοήθεια στη γλώσσα σας δωρεάν Καλέστε τον αριθμό του Τμήματος Υπηρεσιών Μέλους (Member Services) που αναγράφεται στην ταυτότητά σας (ID card) για βοήθεια (TTYTDD 711)

wwwempirebluecom 89

Haitian Avi sa a gen enfogravemasyon enpogravetan sou aplikasyon ou an oswa avantaj ou yo Veye dat enpogravetan yo Ou ka bezwen pran aksyon avan segraveten dat pou kenbe avantaj ou yo oswa jere depans ou yo Ou gen dwa pou resevwa enfogravemasyon sa a ak asistans nan lang ou pou gratis Rele nimewo Manm Segravevis la ki sou kat idantifikasyon ou a pou jwenn egraved (TTYTDD 711) Italian Il presente avviso contiene informazioni importanti relative alla domanda da lei presentata o ai benefici a lei riservati Consulti le date importanti riportate Per continuare a usufruire dei benefici o ricevere assistenza per il pagamento delle spese potrebbe dover eseguire determinate azioni entro scadenze specifiche Ha il diritto di ricevere queste informazioni ed eventuale assistenza nella sua lingua senza alcun costo aggiuntivo Per assistenza chiami il numero dedicato ai Servizi per i membri riportato sul suo libretto (TTYTDD 711) Korean 이 공지사항에는 귀하의 신청서 또는 혜택에 대한 중요한 정보가 있습니다 중요 날짜를 살펴 보십시오 혜택을

유지하거나 비용을 관리하기 위해 특정 마감일까지 조치를 취해야 할 수 있습니다 귀하에게는 무료로 이 정보를

얻고 귀하의 언어로 도움을 받을 권리가 있습니다 도움을 얻으려면 귀하의 ID 카드에 있는 회원 서비스 번호로

전화하십시오 (TTYTDD 711) Polish Niniejsze powiadomienie zawiera istotne informacje dotyczące wniosku lub świadczeń Zwroacuteć uwagę na ważne daty Zachowanie świadczeń lub zarządzanie kosztami może wymagać podjęcia dodatkowych działań w konkretnych terminach Masz prawo do bezpłatnego otrzymania stosownych informacji oraz uzyskania pomocy w swoim języku W tym celu skontaktuj się z Działem Obsługi Klienta pod numerem telefonu podanym na karcie identyfikacyjnej (TTYTDD 711) Russian Настоящее уведомление содержит важную информацию о вашем заявлении или выплатах Обратите внимание на контрольные даты Для сохранения права на получение выплат или помощи с расходами от вас может потребоваться выполнение определенных действий в указанные сроки Вы имеете право получить данную информацию и помощь на вашем языке бесплатно Для получения помощи звоните в отдел обслуживания участников по номеру указанному на вашей идентификационной карте (TTYTDD 711) Tagalog May mahalagang impormasyon ang abisong ito tungkol sa inyong aplikasyon o mga benepisyo Tukuyin ang mahahalagang petsa Maaaring may kailangan kayong gawin sa ilang partikular na petsa upang mapanatili ang inyong mga benepisyo o mapamahalaan ang mga gastos May karapatan kayong makuha ang impormasyon at tulong na ito sa ginagamit ninyong wika nang walang bayad Tumawag sa numero ng Member Services na nasa inyong ID card para sa tulong (TTYTDD 711) Urdu

کو اپ لیے کرنےکے منظم کو لاگتوں یا فائدوں اپنے دیکھیے تاریخیں اہم ہے مشتمل پر معلومات اہم میں بارے کے فائدوں یا درخواست کی اپ نوٹس یہ ڈی ائی اپنے لیے کے مدد ہے حق کا کےحصول مدد اور معلومات ان مفت میں زبان اپنی کو اپ ہے ہوسکتی ضرورت کی کرنے اقدام پر تاریخوں بعض (TTYTDD711 )کریں کال کو نمبر سروس ممبر موجود پر کارڈ

90 wwwempirebluecom

Yiddish

מעלדונג דעם אין דאטעס נויטיגע פאר קוקט קאווערידזש אדער אפלעקאציע אייער וועגן אינפארמאציע וויכטיגע האט מעלדונג דעם האט איר קאסט מיט העלפן אדער קאווערידזש געזונט אייערע האלטן צו דעדליינז געוויסע קודם אקציע נעמען דארפן מעגליך וועט איר

קארטל אייער אויף נומער באדינונגען מעמבער די רופט בחינם שפראך אייער אין הילפט און אינפארמאציע דעם באקומען צו רעכט די(TTYTDD711)הילף פאר

Itrsquos important we treat you fairly Thatrsquos why we follow federal civil rights laws in our health programs and activities We donrsquot discriminate exclude people or treat them differently on the basis of race color national origin sex age or disability For people with disabilities we offer free aids and services For people whose primary language isnrsquot English we offer free language assistance services through interpreters and other written languages Interested in these services Call the Member Services number on your ID card for help (TTYTDD 711) If you think we failed to offer these services or discriminated based on race color national origin age disability or sex you can file a complaint also known as a grievance You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator PO Box 27401 Mail Drop VA2002-N160 Richmond VA 23279 Or you can file a complaint with the US Department of Health and Human Services Office for Civil Rights at 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 or by calling 1-800-368-1019 (TDD 1- 800-537-7697) or online at httpsocrportalhhsgovocrportallobbyjsf Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

2 wwwempirebluecom

OUR ROLE IN NOTIFYING YOU There may be times when benefits andor procedures may change We or your employer will notify you of any change in writing Announcements will go directly to you at the address that appears on our records or to your group benefits office

CONFORMITY WITH LAW Any term of this Booklet which is in conflict with any applicable federal law will be amended to conform with the minimum requirements of such law

wwwempirebluecom 3

Manage Your Healthcare Online

REGISTER NOW TO DO IT ON THE WEB

Go to wwwempirebluecom where you can securely manage your health plan 24 hours a day 7 days a week Herersquos what you can do

x Check status of claims x Search for doctors and specialists x Update your member profile x Get health information and tools with My

Health powered by WebMD

x Print plan documents x Receive information through your personal ldquoMessage Centerrdquo x Visit the Pharmacy

Plus much more hellip

HERErsquoS WHAT YOUrsquoLL NEED TO DO

All members of your family 18 or older must register separately x Go to wwwempirebluecom x Click on the Member tab and choose

ldquoRegisterrdquo

x Follow the simple registration instructions

GET PERSONALIZED HEALTH INFORMATION ndash INCLUDING YOUR HEALTH IQ

Click on MY HEALTH from your secure homepage after you register to receive the following features x Take the Health IQ test and compare your score to others in your age group x Find out how to improve your score ndash and your health ndash online x Find out how to take action against chronic and serious illnesses

Get health information for you and your family

YOUR PRIVACY IS PROTECTED

Your information is protected by one of the most advanced security methods available

Register today to experience hassle-free service wwwempirebluecom

4 wwwempirebluecom

Your PPO Guide

Introduction GETTING ANSWERS YOUR WAY 5

Using Your PPO KNOW THE BASICS 6 YOUR BENEFITS AT A GLANCE 10 DOCTORrsquoS SERVICES 17 EMERGENCY CARE 20 MATERNITY CARE 22 HOSPITAL SERVICES 23 DURABLE MEDICAL EQUIPMENT AND SUPPLIES 25 HOME HEALTH CARE 27 PHYSICAL OCCUPATIONAL SPEECH OR VISION THERAPY 28 BEHAVIORAL HEALTHCARE 29 EMPIRE PHARMACY PROGRAM 30 EXCLUSIONS AND LIMITATIONS 40

Health Management EMPIRErsquoS MEDICAL MANAGEMENT PROGRAM 42 NEW MEDICAL TECHNOLOGY 46 CASE MANAGEMENT 46 PREVENTIVE SERVICES 47 WELLNESS PROGRAMS 50

Details and Definitions ELIGIBILITY 51 CLAIMS 52 REIMBURSEMENT FOR COVERED SERVICES 56 COMPLAINTS APPEALS AND GRIEVANCES 59 ENDING AND CONTINUING COVERAGE 63 YOUR RIGHTS AND RESPONSIBILITIES 65 DEFINITIONS 66 AUDIOHEALTH LIBRARY TOPICS 70 2016 AMENDMENT 75 2017 AMENDMENT 77 2018 AMENDMENT 82 GET HELP IN YOUR LANGUAGE 88

wwwempirebluecom 5

Introduction Getting Answers Your Way Empire gives you more choices for contacting us with your customer service questions Use the Internet phone or mail to get the information you need when you need it

ON THE INTERNET Do you have customer service inquiries and need an instant response Visit wwwempirebluecom At Empire we understand that getting answers quickly is important to you Most benefit claims or membership questions can be addressed online quickly simply and confidentially Nervous about using your PC for important healthcare questions or transactions Wersquove addressed that too Just ldquosend us an e-mail

BY TELEPHONE

WHAT WHY WHERE MEMBER SERVICES For questions about your benefits claims

or membership To locate a participating behavioral healthcare provider in your area Precertification of mental health and alcoholsubstance abuse care

1-855-519-9537 TDD for hearing impaired 1-800-682-8786 830 am to 500 pm Monday ndash Friday

ATT SERVICIOS PARA IDIOMAS EXTRANJEROS

Si usted no habla ingleacutes 1-800-342-9816 Por favor permanezca en la liacutenea y espere que la grabacioacuten termine Un representante de servicios a los miembros contestaraacute la liacutenea y le conectaraacute con un traductor 900 am a 500 pm de Lunes ndash Viernes

BLUECARDreg PPO PROGRAM Get network benefits while you are away from home Locate a PPO provider outside Empirersquos network service area

1-800-810-BLUE (2583) wwwbcbscom 24 hours a day 7 days a week

MEDICAL MANAGEMENT PROGRAM Precertification of hospital admissions and certain treatments and procedures

1-855-519-9537 830 am to 500 pm Monday ndash Friday

247 NURSELINE AND AUDIOHEALTH LIBRARY

Speak with a specially trained nurse to get health information and instructions on how to listen to the tapes

1-877-TALK-2RN (825-5276) 24 hours a day 7 days a week

EMPIRErsquoS PHARMACY PROGRAM Information about the program Locate a participating retail pharmacy Obtain a complete drug formulary list

1-800-342-9816 TDD for hearing impaired 1-800-682-8786 700 am to 1000 pm Monday ndash- Friday 900 am to 900 pm Saturday 900 am to 530 pm Sunday

FRAUD HOTLINE Help prevent health insurance fraud 1-800-I-C-FRAUD (423-7283) 900 am to 500 pm Monday ndash Friday

IN WRITING Empire BlueCross BlueShield PPO Member Services PO Box 1407 Church Street Station New York NY 10008-1407

6 wwwempirebluecom

Using Your PPO

Know the Basics The key to using your PPO plan is understanding how benefits are paid Start by choosing in-network or out-of-network services any time you need healthcare Your choice determines the level of benefits you will receive

You can view and print up-to-date information about your plan or request that information be mailed to you by visiting wwwempirebluecom

CHOOSING IN-NETWORK OR OUT-OF-NETWORK SERVICES In-network services are healthcare services provided by a doctor hospital or healthcare facility that has been selected by Empire or another Blue Cross andor Blue Shield plan to provide care to our members When you choose in-network care you get these advantages

x CHOICE ndash You can choose any participating provider from the largest network of doctors and hospitals in New York State or the network of Blue Cross and Blue Shield plans through the BlueCardreg PPO Program

x FREEDOM ndash You do not need a referral to see a specialist so you direct your care x LOW COST ndash Benefits are paid after a co-payment OR deductible and coinsurance payment for office visits and

many other services x BROAD COVERAGE ndash Benefits are available for a broad range of healthcare services including visits to specialists

physical therapy and home health care x CONVENIENCE ndash Usually there are no claim forms to file x Out-of-network services are healthcare services provided by a licensed provider outside Empirersquos PPO network or the

BlueCard PPO networks of other Blue Cross andor Blue Shield plans For most services you can choose in-network or out-of-network However some services are only available in-network When you use out-of-network services You pay an annual deductible and coinsurance plus any amount above the maximum allowed amount (the

maximum Empire will pay for a covered service) This amount is currently 275 of Medicarersquos Fee Schedule (except for physical therapy services which is 200 of Medicarersquos Fee Schedule and Certified Social Worker which is 225 of Medicarersquos Fee Schedule) if you use a BlueCard provider you will pay only the lower of billed charges or a negotiated rate and your member liability

You will usually have to pay the provider when you receive care You will need to file a claim to be reimbursed by Empire

wwwempirebluecom 7

The following chart shows your specific plan information as of July 1 2013 See the Details and Definitions section for explanations of terms in the chart

IN-NETWORK OUT-Of-NETWORK

ANNUAL DEDUCTIBLE $0 $250Individual $750Family

CO-PAYMENT (for office visits and certain covered services)

$15 per visit (Non-Specialist)

$20 per visit (Specialist)

NA

CO-PAYMENT (for hospital inpatient admissions)

$0 NA

CO-PAYMENT (for emergency room) $75 per visit (waived if admitted to hospital within 24 hours)

$75 per visit (waived if admitted to hospital within 24 hours)

COINSURANCE NA You pay 20 of allowed amount Plan pays 80 of maximum allowed amount

ANNUAL OUT-OF-POCKET LIMIT

(includes Deductible Coinsurance Copayments and cost sharing for Prescription drug coverage)

NA $1250Individual $3250Family

LIFETIME MAXIMUM Unlimited Unlimited

COST SHARE CREDIT If on the day before the effective date of this benefit booklet a member was covered under a group major medical or extended medical contract issued to your group by us or another carrier any covered expenses applied to the in-network and out-of-network deductible and in-network and out-of-network out-of-pocket limit incurred by the member under the prior group contract during the same benefit period will be applied to the satisfaction of any in-network and out-of-network deductible and in-network and out-of-network out-of-pocket limit required under this benefit booklet during the same benefit period for such member for that year only This applies only to members who are covered on the initial effective date of the new benefit booklet with us

HOW TO ACCESS PRIMARY AND SPECIALTY CARE SERVICES Your health plan covers certain primary and specialty care services To access primary care services simply visit any network physician who is a general or family practitioner internist or pediatrician Your health plan covers care provided by any network specialty care provider you choose Referrals are never needed to visit any network specialty care provider To make an appointment call your physicianrsquos office

x Tell them you are an Empire member x Have your Member ID card handy They may ask you for your group number member ID number or

office visit copay x Tell them the reason for your visit

When you go for your appointment take your Member ID card

WHEN YOU NEED CARE AFTER NORMAL OFFICE HOURS After hours care is provided by your physician who may have a variety of ways of addressing your needs Call your physician for instructions on how to receive medical care after their normal business hours on weekends and holidays This includes information about how to receive non-Emergency Care and non-Urgent Care within the service area for a condition that is not life threatening but that requires prompt medical attention If you have an emergency call 911 or go to the nearest emergency room

8 wwwempirebluecom

WHERE TO FIND NETWORK PROVIDERS Empirersquos PPO network gives you access to providers within the planrsquos operating area of 28 eastern New York State counties See ldquooperating areardquo in the Details and Definitions section for a listing of counties

To locate a provider in Empirersquos operating area visit wwwempirebluecom You can search for providers by name address language spoken specialty and hospital affiliation The search results include a map and directions to the providerrsquos office Or ask your Benefits Administrator to see Empirersquos PPO Directory

You can also request that a directory be mailed to you free of charge by calling Member Services at 1-855-519-9537 Call 1-800-810-BLUE (2583) or visit wwwbcbscom to locate participating BlueCard PPOreg providers

TRANSITIONAL CARE Networks grow and change and sometimes a provider will move or leave the network that serves your Plan If you are an existing member and the provider with whom you are in an ongoing course of treatment leaves the network Empire will notify you at least 30 calendar days prior to the physicianrsquos termination or within 15 days after we become aware of the providerrsquos change in status You may continue to receive medically necessary covered services from a provider for an ongoing course of treatment for up to 90 days after heshe leaves the network if the provider agrees to (1) reimbursement at the rates applicable prior to start of transitional care (2) to adhere to the planrsquos quality assurance requirements (3) to provide the plan with necessary medical information related to this care and (4) to adhere to the plans policies and procedures After 90 days you must select a new provider Continued care is available to pregnant women who are in the second and third trimester through the delivery and postpartum period You must contact our Medical Management department to arrange this continued care Transitional care will not be approved if the provider leaves the network due to imminent harm to patient care a determination of fraud or a final disciplinary action by a state licensing board (or other governmental agency) that impairs the health care professionalrsquos ability to practice New plan members who are in treatment for a disabling and degenerative or life threatening condition or disease are eligible for up to 60 days of continued care following their initial enrollment date Members who are pregnant and in their second or third trimester on the effective date of coverage may continue care through delivery and the postpartum period The provider must agree to (1) reimbursement at the rates applicable prior to start of transitional care (2) to adhere to the planrsquos quality assurance requirements (3) to provide the plan with necessary medical information related to this care and (4) to adhere to the plans policies and procedures in both situations You must contact our Medical Management department to arrange this continued care

INTER-PLAN PROGRAMS Out-of-Area Services

Empire has a variety of relationships with other Blue Cross andor Blue Shield Licensees referred to generally as ldquoInter-Plan Programsrdquo Whenever you obtain healthcare services outside of Empirersquos service area the claims for these services may be processed through one of these Inter-Plan Programs which include the BlueCard Program and may include negotiated National Account arrangements available between Empire and other Blue Cross and Blue Shield Licensees

Typically when accessing care outside Empirersquos service area you will obtain care from healthcare providers that have a contractual agreement (ie are ldquoparticipating providersrdquo) with the local Blue Cross andor Blue Shield Licensee in that other geographic area (ldquoHost Bluerdquo) In some instances you may obtain care from nonparticipating healthcare providers Empirersquos payment practices in both instances are described below

BlueCardreg Program Under the BlueCardreg Program when you access covered healthcare services within the geographic area served by a Host Blue Empire will remain responsible for fulfilling Empirersquos contractual obligations However the Host Blue is responsible for contracting with and generally handling all interactions with its participating healthcare providers

Whenever you access covered healthcare services outside Empirersquos service area and the claim is processed through the BlueCard Program the amount you pay for covered healthcare services is calculated based on the lower of

x The billed covered charges for your covered services or x The negotiated price that the Host Blue makes available to Empire

Often this ldquonegotiated pricerdquo will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider Sometimes it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements incentive payments andor other credits or charges Occasionally it may

wwwempirebluecom 9

be an average price based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price

Estimated pricing and average pricing going forward also take into account adjustments to correct for over- or underestimation of modifications of past pricing for the types of transaction modifications noted above However such adjustments will not affect the price Empire uses for your claim because they will not be applied retroactively to claims already paid

Laws in a small number of states may require the Host Blue to add a surcharge to your calculation If any state laws mandate other liability calculation methods including a surcharge we would then calculate your liability for any covered healthcare services according to applicable law

Under certain circumstances if Empire pays the healthcare provider amounts that are your responsibility such as Deductibles Copayments or Coinsurance Empire may collect such amounts directly from you You agree that Empire has the right to collect such amounts from you

Non-Participating Healthcare Providers Outside Empirersquos Service Area Your Liability Calculation

When covered healthcare services are provided outside of Empirersquos service area by non-participating healthcare providers the amount you pay for such services will generally be based on either the Host Bluersquos nonparticipating healthcare provider local payment or the pricing arrangements required by applicable state law In these situations you may be liable for the difference between the amount that the non-participating healthcare provider bills and the payment Empire will make for the Covered Services as set forth in this paragraph

Exceptions

In certain situations Empire may use other payment bases such as billed covered charges the payment we would make if the healthcare services had been obtained within our Service Area or a special negotiated payment as permitted under Inter-Plan Programs Policies to determine the amount Empire will pay for services rendered by nonparticipating healthcare providers In these situations you may be liable for the difference between the amount that the non-participating healthcare provider bills and the payment Empire will make for the covered services as set forth in this paragraph

BLUECARDreg PPO PROGRAM Care When you are Out of Our Service Area Within the US

If you are traveling outside the Empire service area the BlueCardreg PPO program lets you use other Blue Cross andor Blue Shield plansrsquo PPO networks of physicians hospitals and other health care providers As a PPO member you are automatically enrolled in the BlueCardreg PPO program This allows you to receive in-network benefits across the country outside of our network area from providers participating with other Blue Plansrsquo PPO networks As long as these services are covered services under your Contract or Certificate they will be treated as in-network services If you are traveling and need medical care call 1-800-810-BLUE (2583) for the names and addresses of the PPO providers nearest you You may also visit the Blue Cross and Blue Shield Association Web site to locate providers in other states at wwwbcbscom BlueCardpound Worldwide Program The BlueCard Worldwide program provides hospital and professional coverage through an international network of healthcare providers With this program yoursquore assured of receiving care from licensed healthcare professionals The program also assures that at least one staff member at the hospital will speak English or the program will provide translation assistance Herersquos how to use BlueCard Worldwide

x Call 1-804-673-1177 24 hours a day seven days a week for the names of participating doctors and hospitals Outside the US you may use this number by dialing an ATampT Directreg1 Access Number

x Show your Empire ID card at the hospital If yoursquore admitted you will only have to pay for expenses not covered by your contract such as co-payments coinsurance deductibles and personal items Remember to call Empire within 24 hours or as soon as reasonably possible

x If you receive outpatient hospital care or care from a doctor in the BlueCard Worldwide Program pay the bill at the time of treatment When you return home submit an international claim form and attach the bill This claim form is available from the healthcare provider or by calling the BlueCard Worldwide Program Mail the claim to the address on the form You will receive reimbursement less any coinsurance amount above the maximum allowed amount

10 wwwempirebluecom

Your Benefits at a Glance

Empirersquos plan provides a broad range of benefits to you and your family Following is a brief overview of your coverage Some services require precertification with Empirersquos Medical Management Program See the Health Management section for details

YOU PAY

HOME OFFICEOUTPATIENT CARE IN-NETWORK OUT-OF-NETWORK

HOMEOFFICE VISITS $15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

ONLINE VISITS $15 Primary co-payment per visit

Deductible and 20 coinsurance

SPECIALIST VISITS $20 co-payment per visit Deductible and 20 coinsurance

CHIROPRACTIC CARE x Up to an annual in-network and out of network maximum of $1000

$15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

SECOND OR THIRD SURGICAL OPINION $10 co-payment per visit Deductible and 20 coinsurance

DIABETES EDUCATION AND MANAGEMENT $10 co-payment per visit Deductible and 20 coinsurance

ALLERGY CARE x Office Visit x Testing x Treatment

$15 per visit (Non-Specialist) $20 per visit (Specialist) $0 $0

Deductible and 20 coinsurance

SURGERY $0 Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

Empirersquos Medical Management Program must be contacted to determine medical necessity of all in-network and out-of-network chiropractic care after

the fifth visit We will not pay for any visits which we determine were not medically necessary in accordance with your contract

wwwempirebluecom 11

YOU PAY

HOME OFFICEOUTPATIENT CARE IN-NETWORK OUT-OF-NETWORK

DIAGNOSTIC PROCEDURES

x X-rays and other imaging x Laboratory tests

$0 $0

Deductible and 20 coinsurance

CHEMOTHERAPY $0 Deductible and 20 coinsurance

HIGH COST DIAGNOSTIC TESTS (ie MRIsMRAs Nuclear cardiology servicesPETCAT scans)

$0 Deductible and 30 coinsurance

RADIATION $0 Deductible and 20 coinsurance

PRE-SURGICAL TESTING $0 Deductible and 20 coinsurance

ANESTHESIA $0 Deductible and 20 coinsurance

KIDNEY DIALYSIS $0 Deductible and 20 coinsurance

SECOND OR THIRD MEDICAL OPINION FOR CANCER DIAGNOSIS

$15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

CARDIAC REHABILITATION $15 per visit (Non-Specialist)

$20 per visit (Specialist) Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

12 wwwempirebluecom

YOU PAY

HOME OFFICEOUTPATIENT CARE IN-NETWORK OUT-OF-NETWORK

ANNUAL PHYSICAL EXAM x One per calendar year

$15 per visit (Non-Specialist)

$20 per visit (Specialist) Not covered

DIAGNOSTIC SCREENING TESTS x Cholesterol 1 every 2 years (except for triglyceride testing) x Diabetes (if pregnant or considering pregnancy) x Colorectal cancer

ndash Fecal occult blood test if age 40 or over 1 per year ndash Sigmoidoscopy if age 40 or over 1 every 2 years

x Routine Prostate Specific Antigen (PSA) in asymptomatic males ndash Over age 50- 1 every year ndash Between ages 40-49 if risk factors exist 1 per year ndash If prior history of prostate cancer PSA at any age ndash Diagnostic PSA 1 per year

$0 $0

$0

$0

Deductible and 20 coinsurance

WELL-WOMAN CARE x Office visits x Pap smears x Bone Density testing and treatment

ndash Ages 55 through 65 - 1 baseline ndash Age 65 and older - 1 every 2 years (if baseline before

age 65 does not indicate osteoporosis) ndash under Age 65 - 1 every 2 years (if baseline before age

65 indicates osteoporosis) x Mammogram (based on age and medical history)

ndash Ages 35 through 39 ndash 1 baseline ndash Age 40 and older ndash 1 per year

x Womenrsquos sterilization procedures and counseling x Breastfeeding support supplies and counseling

ndash One breast pump per pregnancy x Screenings andor counseling for Gestational diabetes

Human Papillomavirus (HPV) sexually transmitted infections STIs) Human immune deficiency (HIV) interpersonal and domestic violence

$15 per visit (Non-Specialist) $20 per visit (Specialist)

$0 $0

$0

$0 $0

$0

Deductible and 20 coinsurance

WELL-CHILD CARE (covered services and the number of visits are based on the prevailing clinical standards of the American Academy of Pediatrics) x In-hospital visits

ndash Newborn 2 in-hospital exams at birth following vaginal delivery

ndash Newborn 4 in-hospital exams at birth following c-section delivery

x Office visits ndash From birth up 1st birthday 7 visits ndash Ages 1 through 4 years of age 6 visits ndash Ages 5 through 11 years of age 7 visits ndash Ages 12 up to 17 years of age 6 visits ndash Ages 18 to 19th birthday 2 visits

x Lab tests x Immunizations (office visits are not required)

$0

$0

$0 $0

$0

$0

Deductible and 20 coinsurance Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements See the Preventive Care section for more details

wwwempirebluecom 13

YOU PAY

EMERGENCY CARE IN-NETWORK OUT-OF-NETWORK

EMERGENCY ROOM $75 per visit co-payment (waived if admitted to the same hospital within 24 hours)

PHYSICIANrsquoS OFFICE $15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

EMERGENCY AIR AMBULANCE x Transportation to nearest acute care hospital for

emergency inpatient admissions

$0

Covered in-network when specified criteria is met subject to any applicable cost sharing You may be required to pay the difference between the maximum allowed amount and the total charges of an out-of-network provider

EMERGENCY LAND AMBULANCE x Local professional ground ambulance to

nearest hospital $0 up to the maximum allowed

amount

Covered in-network subject to meeting emergency criteria When services are delivered by an out-of-network land ambulance provider that is not licensed under the NY Public Health Law you may be required to pay up to the difference between the maximum allowed amount and the providerrsquos total charges13

MATERNITY CARE IN-NETWORK OUT-OF-NETWORK

PRENATAL AND POSTNATAL CARE (In doctorrsquos office) $0 Deductible and 20 coinsurance

LAB TESTS SONOGRAMS AND OTHER DIAGNOSTIC PROCEDURES $0 Deductible and 20 coinsurance

ROUTINE NEWBORN NURSERY CARE (In hospital) $0 Deductible and 20 coinsurance

OBSTETRICAL CARE (In hospital) $0 Deductible and 20 coinsurance

OBSTETRICAL CARE (In birthing center) $0 Not covered

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

13 New York State law prohibits land ambulance providers in New York State from balance-billing beyond reasonable and customary amounts (you will be responsible for in-network cost share such as co-payments deductibles and coinsurance)

14 wwwempirebluecom

YOU PAY

HOSPITAL SERVICES IN-NETWORK OUT-OF-NETWORK

SEMI-PRIVATE ROOM AND BOARD $0 Deductible and 20 coinsurance

ANESTHESIA AND OXYGEN $0 Deductible and 20 coinsurance

CHEMOTHERAPY AND RADIATION THERAPY $0 Deductible and 20 coinsurance

DIAGNOSTIC X-RAYS AND LAB TESTS $0 Deductible and 20 coinsurance

DRUGS AND DRESSINGS $0 Deductible and 20 coinsurance

GENERAL SPECIAL AND CRITICAL NURSING CARE $0 Deductible and 20 coinsurance

INTENSIVE CARE $0 Deductible and 20 coinsurance

KIDNEY DIALYSIS $0 Deductible and 20 coinsurance

SERVICES OF LICENSED PHYSICIANS AND SURGEONS $0 Deductible and 20 coinsurance

SURGERY (Inpatient and Outpatient) $0 Deductible and 20 coinsurance

DURABLE MEDICAL EQUIPMENT AND SUPPLIES IN-NETWORK OUT-OF-NETWORK

DURABLE MEDICAL EQUIPMENT (ie hospital-type bed wheelchair sleep apnea monitor)

$0 Not covered

ORTHOTICS $0 Not covered

PROSTHETICS (ie artificial arms legs eyes ears) $0 Not covered

MEDICAL SUPPLIES (ie catheters oxygen syringes) $0

Difference between the maximum allowed amount and the total charge ( coinsurance does not apply)

NUTRITIONAL SUPPLEMENTS (enteral formulas and modified solid food products)

$0 Deductible and 20 coinsurance

HEARING AIDS (one device per ear every 3 years maximum of $1500 combined in and out-of-network) $0 Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

Does not include inpatient or outpatient behavioral healthcare or physical therapyrehabilitation For a second procedure performed during an authorized surgery through the same incision Empire pays for the procedure with the higher maximum allowed amount For a second procedure done through a separate incision Empire will pay the maximum allowed amount for the procedure with the higher allowance and up to 50 of the maximum allowed amount for the other procedure $0 outside of the United States

wwwempirebluecom 15

YOU PAY

SKILLED NURSING AND HOSPICE CARE IN-NETWORK OUT-OF-NETWORK

SKILLED NURSING FACILITY Up to 120 days per calendar year $0 Not covered

HOSPICE Unlimited days per lifetime $0 Not covered

HOME HEALTH CARE IN-NETWORK OUT-OF-NETWORK

HOME HEALTH CARE

Up to 200 visits per calendar year (a visit equals 4 hours of care)

$0

Deductible and 20 coinsurance only

HOME INFUSION THERAPY $0 Not covered

PHYSICAL OCCUPATIONAL SPEECH OR VISION THERAPY IN-NETWORK OUT-OF-NETWORK

PHYSICAL THERAPY AND REHABILITATION

x Up to 60 days of inpatient service per calendar year

x Up to 60 visits combined in home office or outpatient facility per calendar year

$20 per visit (Specialist)

$15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

Deductible and 20 coinsurance

OCCUPATIONAL AND SPEECH THERAPY

x Up to 60 visits per person combined in home office or outpatient facility per calendar year

$15 per visit (Non-Specialist) $20 per visit (Specialist) Deductible and 20 coinsurance

VISION THERAPY

x Up to 60 visits per person combined in home or office per calendar year

$15 per visit (Non-Specialist) $20 per visit (Specialist) Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

Treatment maximums are combined for in-network and out-of-network care $0 outside of the United States

16 wwwempirebluecom

YOU PAY

MENTAL HEALTH CARE IN-NETWORK OUT-OF-NETWORK

OUTPATIENT x Up to 60 visits per calendar year 1

$25 co-payment Deductible and 20 coinsurance

INPATIENT x Up to 90 days per calendar year 1

x Up to 90 visits from mental health care professionals

per calendar year 1

$0

$0

Deductible and 20 coinsurance

Deductible and 20 coinsurance

ALCOHOL OR SUBSTANCE ABUSE TREATMENT IN-NETWORK OUT-OF-NETWORK

OUTPATIENT x Up to 60 visits per calendar year including up to

20 visits for family counseling $0 Deductible and 20 coinsurance

INPATIENT x Up to 7 days detoxification per calendar year 1 x Up to 30 days rehabilitation per calendar year 1

$0 $0

Deductible and 20 coinsurance

Deductible and 20 coinsurance

PHARMACY (RETAIL AND MAIL SERVICE) IN-NETWORK OUT-OF-NETWORK

RETAIL PHARMACY (34 day supply) x Tier 1 x Tier 2

x Tier 3

x 20 co-payment $5 minimum and up to a maximum of $20 per prescription

x 25 co-payment $5 minimum and up to a maximum of $30 per prescription

x 25 co-payment $5 minimum and up to a maximum of $30 per prescription

x

40 Coinsurance

(within the United States)

20 Coinsurance

(outside the United States)

x

MAIL SERVICE (90 day supply-includes some specific Retail locations)

x $15 co-payment Not covered

Generic and Select Oral Contraceptives and Contraceptive Devices

x $0 cost share Not covered

(All of the prescription drug options listed above meet the Centers for Medicare and Medicaid Services (CMS) standards for Medicare prescription drug coverage and each option is considered Creditable Coverage under the Medicare Modernization Act of 2003)

OTHER SERVICES IN-NETWORK OUT-OF-NETWORK SEX CHANGE SURGERY OR TREATMENT OF GENDER IDENTITY DISORDERS (for hospital inpatient only) x Lifetime Maximum $75000 for transformative surgeries

Lifetime Maximum combined In-network and Out-of-Network

$0 Deductible and 20 coinsurance

Treatment maximums are combined for in-network and out-of-network care

wwwempirebluecom 17

Coverage

Doctorrsquos Services When you need to visit your doctor or a specialist Empire makes it easy In-network you pay only a co-payment There are no claim forms to fill out for X-rays blood tests or other diagnostic procedures ndash as long as they are requested by the doctor and done in the doctorrsquos office or a network facility For in-network allergy office visits you pay only a co-payment In-network allergy testing is covered in full Ongoing in-network allergy treatments are covered in full

When you visit an out-of-network physician or use an out-of-network facility for diagnostic procedures including allergy testing and treatment visits you pay the deductible and coinsurance plus any amount above Empirersquos allowed amount

Tips For Visiting Your Doctor x When you make your appointment confirm that the doctor is an Empire network provider and that heshe is

accepting new patients

x Arrange ahead of time to have pertinent medical records and test results sent to the doctor

x If the doctor sends you to an outside lab or radiologist for tests or X-rays call Member Services to confirm that the supplier is in Empirersquos network This will ensure that you receive maximum benefits

Ask about a second opinion anytime that you are unsure about surgery or a cancer diagnosis The specialist who provides the second or third opinion cannot perform the surgery To confirm a cancer diagnosis or course of treatment second or third opinions are paid at the in-network level even if you use an out-of-network specialist as long as your participating doctor provides a written referral to a non-participating specialist If you visit a non-participating specialist without a written referral you must pay the out-of-network deductible and coinsurance

WOMENrsquoS HEALTH AND CANCER RIGHTS OF ACT 1998

This federal law applies to almost all health care plans except Medicare Supplement and Medicare Risk plans as of plan years beginning on or after October 21 1998 The law imposes certain requirements on employee benefit plans and health insurers that provide medical and surgical benefits with respect to a mastectomy Specifically in the case of a participant or beneficiary who receives benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy the law requires coverage for

x Reconstruction of the breast on which the mastectomy has been performed x Surgery and reconstruction of the other breast to produce a symmetrical appearance x Prostheses and treatment of physical complications at all stages of mastectomy including lymphedemas

The coverage described above shall be provided in a manner determined in consultation with the attending physician and the patient This coverage is subject to all coverage terms and limitations (for example Deductibles and Coinsurance) consistent with those established for other benefits under the plan

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Consultation requested by the attending physician for advice on an illness or injury

This includes the Specialist e-Consultations Program If Your Participating Provider is in Our Cooperative Care program and is rendering primary care services to You he or she may request an electronic consultation with a Specialist to help evaluate Your condition or diagnosis The electronic consultation will be provided by a Participating Provider who has agreed to participate in Our ldquoeconsultationrdquo program and will be selected by Your Participating Provider in his or her clinical judgement The electronic consultation will be at no cost to You Your Participating Provider may consider the information provided by the Specialist in determining Your treatment The consultation will be conducted using electronic information and communication technologies such as secure web-based email fax andor exchange of electronic medical records The results may be documented in an electronic health record

x Diabetes supplies prescribed by an authorized provider Blood glucose monitors including monitors for the legally blind

18 wwwempirebluecom

Testing strips Insulin syringes injection aids cartridges for the legally blind insulin pumps and appurtenances and insulin

infusion devices Oral agents for controlling blood sugar Other equipment and supplies required by the New York State Health Department Data management systems

x Diabetes self-management education and diet information including

Education by a physician certified nurse practitioner or member of their staff frac34 At the time of diagnosis frac34 When the patientrsquos condition changes significantly frac34 When medically necessary

Education by a certified diabetes nurse educator certified nutritionist certified dietitian or registered dietitian when referred by a physician or certified nurse practitioner This benefit may be limited to a group setting when appropriate

Home visits for education when medically necessary

x Diagnosis and treatment of degenerative joint disease related to temporomandibular joint (TMJ) syndrome that is not a dental condition

x Diagnosis and treatment for Orthognathic surgery that is not a dental condition

x Medically necessary hearing examinations

x Foot care and orthotics associated with disease affecting the lower limbs such as severe diabetes which requires care from a podiatrist or physician

x Gender Reassignment Surgery and related non-cosmetic services

Lifetime Maximum benefit of $75000 for transgender surgery Counseling Services are covered These services will not count toward the $75000 Lifetime Maximum Benefit

x Cosmetic Services received in association with gender transformation are NOT covered including

x Reduction Thyroid Chondroplasty x Liposuction x Rhinoplasty x Facial Bone Reconstruction x Face Lift x Blepharoplasty x Voice Modification Surgery x Hair Removalhairplasty x Breast Augmentation

ONLINE VISITS

Your coverage includes online physician office visits Covered Services include a medical consultation using the internet via a webcam with online chat or voice functions Services are provided by board certified licensed primary care physicians Online visits are not for specialist care Common types of diagnoses and conditions treated online are cough fever headaches sore throat routine child health issues influenza upper respiratory infections sinusitis bronchitis and urinary tract infections when uncomplicated in nature Online visits are not meant for the following purposes

To get reports of normal lab or other test results To request an office appointment To ask billing insurance coverage or payment questions To ask for a referral to a specialist Doctor To request precertification for a benefit under your health Plan or To ask the physician to consult with another physician

You must have the following computer hardware in order for the online website to work properly USB or built in webcam (to enable two-way video during web conversations) and audio functionality To minimize audio feedback use a headset or headphones with a built-in microphone To begin the online visit log on to wwwlivehealthonlinecom and establish an

wwwempirebluecom 19

online account by providing some basic information about you and your insurance plan Before you connect to a Doctor you will be asked the kind of condition you want to discuss with the Doctor list your local pharmacy provide information for the credit card you want your cost share for the visit to be billed to agree to the terms of use and select an available physician If you are not in New York State when you seek an online visit you will need to check to be sure an online Doctor is available in the state you are in because online Doctors are not available in every state The visit with the physician will not start until you provide the above information and click ldquoconnectrdquo The visit will be documented in an electronic health record You may access your records and print them and may email or fax them to your primary care physician

CLINICAL TRIALS We Cover the routine patient costs for Your participation in an approved clinical trial and such coverage shall not be subject to Utilization Review if You are

x Eligible to participate in an approved clinical trial to treat either cancer or other life-threatening disease or condition and

x Referred by a Participating Provider who has concluded that Your participation in the approved clinical trial would be appropriate

All other clinical trials including when You do not have cancer or other life-threatening disease or condition may be subject to the Utilization Review and External Appeal sections of this booklet We do not Cover the costs of the investigational drugs or devices the costs of non-health services required for You to receive the treatment the costs of managing the research or costs that would not be covered under this benefit plan for non-investigational treatments provided in the clinical trial An ldquoapproved clinical trialrdquo means a phase I II III or IV clinical trial that is

x A federally funded or approved trial x Conducted under an investigational drug application reviewed by the federal Food and Drug Administration or x A drug trial that is exempt from having to make an investigational new drug application

Whatrsquos Not Covered The following medical services are not covered

x Routine foot care including care of corns bunions calluses toenails flat feet fallen arches weak feet and chronic foot strain

x Symptomatic complaints of the feet except capsular or bone surgery related to bunions and hammertoes x Orthotics for treatment of routine foot care x Routine hearing exams x Services such as laboratory X-ray and imaging and pharmacy services as required by law from a facility in which

the referring physician or hisher immediate family member has a financial interest or relationship x Services given by an unlicensed provider or performed outside the scope of the providerrsquos license

20 wwwempirebluecom

Emergency Care IF YOU NEED EMERGENCY CARE

Should you need emergency care your plan is there to cover you Emergency care is covered in the hospital emergency room

To be covered as emergency care the condition must be a medical or behavioral condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in

1 Placing the health of the person afflicted with such condition (or with respect to a pregnant woman the health of the woman or her unborn child) in serious jeopardy or in the case of a behavioral condition placing the health of such person or others in serious jeopardy

2 Serious impairment to such personrsquos bodily functions 3 Serious dysfunction of any bodily organ or part of such person or

4 Serious disfigurement of such person

Emergency Services are defined as a medical screening examination that is within the capability of the emergency department of a Hospital including ancillary services routinely available to the emergency department to evaluate an Emergency Condition and within the capabilities of the staff and facilities available at the Hospital such further medical examination and treatment as are required to stabilize the patient With respect to an emergency medical condition the term ldquoStabilizerdquo means to provide such medical treatment of the condition as may be necessary to assure within reasonable medical probability that no material deterioration of the condition is likely to result from or occur during the transfer of the patient from a facility or to deliver a newborn child (including the placenta)

Emergency Services are not subject to prior authorization requirements

Emergency Assistance 911 In an emergency call 911 for an ambulance or go directly to the nearest emergency room If possible go to the emergency room of a hospital in Empirersquos PPO network or the PPO network of another Blue Cross andor Blue Shield plan

You pay only a co-payment for a visit to an emergency room This co-payment is waived if you are admitted to the hospital within 24 hours If you make an emergency visit to your doctorrsquos office you pay the same co-payment as for an office visit

Benefits for treatment in a hospital emergency room are limited to the initial visit for an emergency condition A participating provider must provide all follow-up care in order to receive maximum benefits Remember You will need to show your Empire BlueCross BlueShield ID card when you arrive at the emergency room

Tips For Getting Emergency Care x If time permits speak to your physician to direct you to the best place for treatment x If you have an emergency while outside Empirersquos service area anywhere in the United States follow the same steps

described on the previous page If the hospital participates with another Blue Cross andor Blue Shield plan in the BlueCardpound PPO program your claim will be processed by the local plan Be sure to show your Empire ID card at the emergency room If the hospital does not participate in the BlueCard PPO program you will need to file a claim

x If you have an emergency outside of the United States and visit a hospital which participates in the BlueCardpound

Worldwide program simply show your Empire ID card The hospital will submit their bill through the BlueCard Worldwide Program If the hospital does not participate with the BlueCard Worldwide program you will need to file a claim

Please refer to the Health Management section for details regarding precertification requirements

wwwempirebluecom 21

Whatrsquos Not Covered These emergency services are not covered

x Use of the Emergency Room To treat routine ailments Because you have no regular physician Because it is late at night (and the need for treatment is not sudden and serious)

Emergency Air Ambulance We will provide in-network coverage for air ambulance services when needed to transport you to the nearest acute care hospital in connection with an emergency room or emergency inpatient admission or emergency outpatient care subject to cost sharing obligations when the following conditions are met

x Your medical condition requires immediate and rapid ambulance transportation and services cannot be provided by land ambulance due to great distances and the use of land transportation would pose an immediate threat to your health

x Services are covered to transport you from one acute care hospital to another only if the transferring hospital does not have adequate facilities to provide the medically necessary services needed for your treatment as determined by Empire and use of land ambulance would pose an immediate threat to your health

If Empire determines that the condition for coverage for air ambulance services has not been met but your condition did require transportation by land ambulance to the nearest acute care hospital Empire will only pay up to the maximum allowed amount that would be paid for land ambulance to that hospital You may be required to pay the difference between the maximum allowed amount and the total charges of an out-of-network provider

Please refer to the Health Management section for details regarding precertification requirements

Emergency Land Ambulance We will provide coverage for land ambulance transportation to the nearest acute care hospital in connection with emergency room care or emergency inpatient admission provided by an ambulance service when a prudent layperson possessing an average knowledge of medicine and health could reasonably expect the absence of such transportation to result in

x placing the memberrsquos health afflicted with a condition in serious jeopardy or for behavioral condition place the health of a member or others in serious jeopardy or

x serious impairment to a personrsquos bodily functions x serious dysfunction of any bodily organ or part of a person or x serious disfigurement to the member

Non-Emergency Ambulance Transportation

We cover non-emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance as appropriate) between facilities when the transport is any of the following

x From a non-participating Hospital to a participating Hospital x To a Hospital that provides a higher level of care that was not available at the original Hospital x To a more cost-effective Acute care Facility or x From an Acute Facility to a sub-Acute setting LimitationsTerms of Coverage

x We do not cover travel or transportation expenses unless connected to an Emergency Condition or due to a Facility transfer approved by us even though prescribed by a Physician

x We do not cover non-ambulance transportation such as ambulette van or taxi cab x Coverage for air ambulance related to an Emergency Condition or air ambulance related to non-emergency

transportation is provided when your medical condition is such that transportation by land ambulance is not appropriate and your medical condition requires immediate and rapid ambulance transportation that cannot be provided by land ambulance and one of the following is met The point of pick-up is inaccessible by land vehicle or Great distances or other obstacles (for example heavy traffic) prevent your timely transfer to the nearest Hospital

with appropriate facilities

22 wwwempirebluecom

Maternity Care IF YOU ARE HAVING A BABY

There are no out-of-pocket expenses for maternity and newborn care when you use in-network providers That means you do not need to pay a co-payment when you visit the obstetrician Furthermore routine tests related to pregnancy obstetrical care in the hospital or birthing center as well as routine newborn nursery care are all covered 100 in-network

For out-of-network maternity services you pay the deductible coinsurance and any amount above the maximum allowed amount Empirersquos reimbursements for the remaining balance may be consolidated in up to three installments as follows

x Two payments for prenatal care x One payment for delivery and post-natal care

Please refer to the Health Management section for details regarding precertification requirements Obstetrical care in the hospital or an in-network birthing center is covered up to 48 hours after a normal vaginal birth and 96 hours after a Cesarean section

NEWBORNSrsquo AND MOTHERSrsquo HEALTH PROTECTION ACT OF 1996 Group health plans and health insurance issuers generally may not under Federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section However Federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under Federal law require that a provider obtain authorization from the Program or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours as applicable) Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x One home care visit if the mother leaves earlier than the 48-hour (or 96-hour) limit The mother must request the visit from the hospital or a home health care agency within this timeframe (precertification is not required) The visit will take place within 24 hours after either the discharge or the time of the request whichever is later

x Services of a certified nurse-midwife affiliated with a licensed facility The nurse-midwifersquos services must be provided under the direction of a physician

x Parent education and assistance and training in breast or bottle feeding if available x Circumcision of newborn males x Special care for the baby if the baby stays in the hospital longer than the mother Call Empirersquos Medical Management

Program to precertify the hospital stay x Semi-private room

Whatrsquos Not Covered These maternity care services are not covered

x Days in hospital that are not medically necessary (beyond the 48-hour96-hour limits) x Services that are not medically necessary x Private room x Out-of-network birthing center facilities x Private duty nursing

REMEMBER Use a network obstetriciangynecologist to receive the lowest cost maternity care

wwwempirebluecom 23

Hospital Services IF YOU VISIT THE HOSPITAL

Your plan covers most of the cost of your medically necessary care when you stay at a network hospital for surgery or treatment of illness or injury When you use an out-of-network hospital or facility you pay the deductible and coinsurance plus any amount above Empirersquos maximum allowed amount

You are also covered for same-day (outpatient or ambulatory) hospital services such as chemotherapy radiation therapy cardiac rehabilitation and kidney dialysis Same-day surgical services or invasive diagnostic procedures are covered when they

x Are performed in a same-day or hospital outpatient surgical facility x Require the use of both surgical operating and postoperative recovery rooms x May require either local or general anesthesia x Do not require inpatient hospital admission because it is not appropriate or medically necessary and x Would justify an inpatient hospital admission in the absence of a same-day surgery program

Please refer to the Health Management section for details regarding precertification requirements

Tip For Getting Hospital Care x If you are having same-day surgery often the hospital or outpatient facility requires that someone meet you after the

surgery to take you home Ask about their policy and make arrangements for transportation before you go in for surgery

Inpatient And Outpatient Hospital Care

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations for both inpatient and outpatient (same-day) care

x Diagnostic X-rays and lab tests and other diagnostic tests such as EKGs EEGs or endoscopies x Oxygen and other inhalation therapeutic services and supplies and anesthesia (including equipment for administration x Anesthesiologist including one consultation before surgery and services during and after surgery x Blood and blood derivatives for emergency care same-day surgery or medically necessary conditions such as

treatment for hemophilia x MRIsMRAs PETCAT scans and nuclear cardiology services

Please refer to the Health Management section for details regarding precertification requirements

Inpatient Hospital Care

Whatrsquos Covered Following are additional covered services for inpatient care

x Semi-private room and board when The patient is under the care of a physician and A hospital stay is medically necessary

x Coverage is for unlimited days unless otherwise specified x Operating and recovery rooms x Special diet and nutritional services while in the hospital x Cardiac care unit x Services of a licensed physician or surgeon employed by the hospital x Care related to surgery x Breast cancer surgery (lumpectomy mastectomy) including

Reconstruction following surgery Surgery on the other breast to produce a

symmetrical appearance

Prostheses Treatment of physical complications at any stage of a

mastectomy including lymphedemas The patient has the right to decide in consultation with the physician the length of hospital stay following mastectomy surgery

x Use of cardiographic equipment x Drugs dressings and other medically necessary supplies x Social psychological and pastoral services x Reconstructive surgery associated with injuries unrelated to cosmetic surgery x Reconstructive surgery for a functional defect which is present from birth x Physical occupational speech and vision therapy including facilities services supplies and equipment x Facilities services supplies and equipment related to medically necessary medical care x Residential treatment services are not covered

Please refer to the Health Management section for details regarding precertification requirements

24 wwwempirebluecom

Outpatient Hospital Care

Whatrsquos Covered Following are additional covered services for same-day care

x Same-day and hospital outpatient surgical facilities x Surgeons x Surgical assistant if

None is available in the hospital or facility where the surgery is performed and The surgical assistant is not a hospital employee

x Chemotherapy and radiation therapy including medications in a hospital outpatient department doctorrsquos office or facility Medications that are part of outpatient hospital treatment are covered if they are prescribed by the hospital and filled by the hospital pharmacy

x Kidney dialysis treatment (including hemodialysis and peritoneal dialysis) is covered in the following settings until the patient becomes eligible for end-stage renal disease dialysis benefits under Medicare At home when provided supervised and arranged by a physician and the patient has registered with an approved

kidney disease treatment center (professional assistance to perform dialysis and any furniture electrical plumbing or other fixtures needed in the home to permit home dialysis treatment are not covered

In a hospital-based or free-standing facility See ldquohospitalfacilityrdquo in the Definitions section

Please refer to the Health Management section for details regarding precertification requirements

Inpatient Hospital Care

Whatrsquos Not Covered These inpatient services are not covered

x Private duty nursing x Private room If you use a private room you need to pay the difference between the cost for the private room and the

hospitalrsquos average charge for a semiprivate room The additional cost cannot be applied to your deductible or coinsurance

x Diagnostic inpatient stays unless connected with specific symptoms that if not treated on an inpatient basis could result in serious bodily harm or risk to life

x Services performed in the following Nursing or convalescent homes Institutions primarily for rest or for the aged Rehabilitation facilities (except for physical therapy)

Spas Sanitariums Infirmaries at schools colleges or camps

x Any part of a hospital stay that is primarily custodial x Elective cosmetic surgery or any related complications x Hospital services received in clinic settings that do not meet Empirersquos definition of a hospital or other covered facility

See ldquohospitalfacilityrdquo in the Details and Definitions section

Outpatient Hospital Care

Whatrsquos Not Covered These outpatient services are not covered

x Same-day surgery not precertified as medically necessary by Empirersquos Medical Management Program x Routine medical care including but not limited to

Inoculation or vaccination Drug administration or injection excluding chemotherapy

x Collection or storage of your own blood blood products semen or bone marrow

wwwempirebluecom 25

Durable Medical Equipment and Supplies IF YOU NEED EQUIPMENT OR MEDICAL SUPPLIES

Your plan covers the cost of medically necessary prosthetics orthotics and durable medical equipment from network suppliers only In-network benefits and plan maximums are shown in Your Benefits at a Glance section Out-of-network benefits are not available

Please refer to the Health Management section for details regarding precertification requirements

An Empire network supplier may not bill you for covered services If you receive a bill from one of these providers contact Member Services at 1-855-519-9537

Disposable medical supplies such as syringes are covered up to the maximum allowed amount whether you obtain them in- or out-of-network

Coverage for enteral formulas or other dietary supplements for certain severe conditions is available both in- and out-of network If you have prescription drug coverage with Empirersquos pharmacy program you may order these formulas or supplements through Empirersquos pharmacy program Whatrsquos Covered Covered services are listed in Your Benefits At A Glance section Following are additional covered services and limitations

x Prosthetics orthotics and durable medical equipment from network suppliers when prescribed by a doctor including Artificial arms legs eyes ears nose larynx and external breast prostheses Prescription lenses if organic lens is lacking Supportive devices essential to the use of an artificial limb Corrective braces Wheelchairs hospital-type beds oxygen equipment sleep apnea monitors

x Rental (or purchase when more economical) of medically necessary durable medical equipment x Replacement of covered medical equipment because of wear damage or change in patientrsquos need when ordered by a

physician x Reasonable cost of repairs and maintenance for covered medical equipment x Enteral formulas with a written order from a physician or other licensed health care provider The order must

state that The formula is medically necessary and effective and Without the formula the patient would become malnourished suffer from serious physical disorders or die

x Modified solid food products for the treatment of certain inherited diseases A physician or other licensed healthcare provider must provide a written order

x Hearing aids and the examination for their fitting Please refer to the Health Management section for details regarding precertification requirements

Whatrsquos Not Covered The following equipment is not covered x Air conditioners or purifiers x Humidifiers or dehumidifiers x Exercise equipment

x Swimming pools x False teeth

26 wwwempirebluecom

Skilled Nursing and Hospice Care IF YOU NEED SKILLED NURSING OR HOSPICE CARE

You receive coverage through Empirersquos PPO for inpatient care in a skilled nursing facility or hospice Benefits are available for network facilities only Benefits and plan maximums are shown in Your Benefits at a Glance section

Please refer to the Health Management section for details regarding precertification requirements

Skilled Nursing Care

Whatrsquos Covered You are covered for inpatient care in a network skilled nursing facility if you need medical care nursing care or rehabilitation services The number of covered days is listed in Your Benefits at a Glance section Prior hospitalization is not required in order to be eligible for benefits Services are covered if

x The doctor provides A referral and written treatment plan A projected length of stay

An explanation of the services the patient needs and The intended benefits of care

x Care is under the direct supervision of a physician registered nurse (RN) physical therapist or other healthcare professional

Whatrsquos Not Covered The following skilled nursing care services are not covered

x Skilled nursing facility care that primarily Gives assistance with daily living activities Is for rest or for the aged Treats drug addiction or alcoholism

Convalescent care Sanitarium-type care Rest cures

Hospice Care Empire covers unlimited days of hospice care once in a covered personrsquos lifetime Hospices provide medical and supportive care to patients who have been certified by their physician as having a life expectancy of twelve (12) months or less Hospice care can be provided in a hospice in the hospice area of a network hospital or at home as long as it is provided by a network hospice agency

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Hospice care services including Up to 12 hours of intermittent care each day by a registered nurse (RN) or licensed practical nurse (LPN) Medical care given by the hospice doctor Drugs and medications prescribed by the patientrsquos doctor that are not experimental and are approved for use by

the most recent Physiciansrsquo Desk Reference Physical occupational speech and respiratory therapy when required for control of symptoms Laboratory tests X-rays chemotherapy and radiation therapy Social and counseling services for the patientrsquos family including bereavement counseling visits until one year

after death Transportation between home and hospital or hospice when medically necessary Medical supplies and rental of durable medical equipment Up to 14 hours of respite care in any week

Tips for Receiving Skilled Nursing and Hospice Care x To learn more about a skilled nursing facility ask your doctor or caseworker to see the Health Facilities directory x For hospice care in your home ask whether the same caregiver will come each day or whether you will see someone

new each time What recourse do you have if you are not comfortable with the caregiver

wwwempirebluecom 27

Home Health Care IF YOU NEED HOME HEALTH CARE

Home health care can be an alternative to an extended stay in a hospital or a stay in a skilled nursing facility You receive coverage when you use an in-network provider For out-of-network home health care you pay coinsurance only (the deductible does not apply) Out-of-network agencies must be certified by New York State or have comparable certification from another state Benefits and plan maximums are shown in Your Benefits at a Glance section

Home infusion therapy a service sometimes provided during home health care visits is only available in-network An Empire network home health care agency or home infusion supplier cannot bill you for covered services If you receive a bill from one of these providers contact Member Services at 1-855-519-9537 Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Up to 200 home health care visits per year combined in- and out-of-network A visit is defined as up to four hours of care Care can be given for up to 12 hours a day (three visits) Your physician must certify home health care as medically necessary and approve a written treatment plan

x Home health care services include Part-time services by a registered nurse (RN) or licensed practical nurse (LPN) Part-time home health aide services (skilled nursing care) Physical speech or occupational therapy if restorative Medications medical equipment and supplies prescribed by a doctor Laboratory tests

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Up to 200 home health care visits per year combined in- and out-of-network A visit is defined as up to four hours of care Care can be given for up to 12 hours a day (three visits) Your physician must certify home health care as medically necessary and approve a written treatment plan

x Home health care services include Part-time services by a registered nurse (RN) or licensed practical nurse (LPN) Part-time home health aide services (skilled nursing care) Physical speech or occupational therapy if restorative Medications medical equipment and supplies prescribed by a doctor Laboratory tests

Whatrsquos Not Covered The following home health care services are not covered

x Custodial services including bathing feeding changing or other services that do not require skilled care x Out-of-network home infusion therapy

28 wwwempirebluecom

Physical Occupational Speech or Vision Therapy IF YOU NEED THERAPY

You receive benefits through Empirersquos plan for physical occupational speech and vision therapy Outpatient physical occupational speech and vision therapy services are available in-network and out-of-network Inpatient physical therapy can be in-network or out-of-network

Please refer to the Health Management section for details regarding precertification requirements

Tip for Receiving Therapy x Ask for exercises you can do at home that will help you get better faster

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Physical therapy physical medicine or rehabilitation services or any combination of these on an inpatient or outpatient basis up to the plan maximums if Prescribed by a physician Designed to improve or restore physical functioning within a reasonable period of time and Approved by Empirersquos Medical Management Program (for in-network physical therapy only) Designed to improve or restore physical functioning within a reasonable period of time

Outpatient care must be given at home in a therapistrsquos office or in an outpatient facility by an in-network provider inpatient therapy must be short-term

x Occupational speech or vision therapy or any combination of these on an outpatient basis up to the plan maximums if Prescribed by a physician or in conjunction with a physicianrsquos services Given by skilled medical personnel at home in a therapistrsquos office or in an outpatient facility Performed by a licensed speechlanguage pathologist or audiologist

Whatrsquos Not Covered The following therapy services are not covered

x Therapy to maintain or prevent deterioration of the patientrsquos current physical abilities x Tests evaluations or diagnoses received within the 12 months prior to the doctorrsquos referral or order for occupational

speech or vision therapy

wwwempirebluecom 29

Behavioral Healthcare IF YOU NEED BEHAVIORAL HEALTHCARE

At Empire we realize that your mental health is as important as your physical health Thatrsquos why we include behavioral healthcare benefits at little out-of-pocket cost Your behavioral healthcare benefits cover outpatient treatment for alcohol or substance abuse both in-network and out-of-network and inpatient detoxification in-network and out-of-network Inpatient alcohol and substance abuse rehabilitation in a facility is covered in-network and out-of-network Mental healthcare is covered on an inpatient basis in-network and out-of-network and on an outpatient basis in-network and out-of-network

Please note that with the exception of outpatient alcohol and substance abuse treatment the coinsurance that you pay for out-of-network behavioral healthcare services will not count toward reaching your annual out-of-pocket limit

Please refer to the Health Management section for details regarding precertification requirements

Mental Health Care

Whatrsquos Covered In addition to the services listed in Your Benefits at a Glance section the following mental health care service is covered

x Electroconvulsive therapy for treatment of mental or behavioral disorders if precertified by Behavioral Healthcare Management

x Care from psychiatrists psychologists nurse practitioners or licensed clinical social workers providing psychiatric or psychological services within the scope of their practice including the diagnosis and treatment of mental and behavioral disorders Social workers must be licensed by the New York State Education Department or a comparable organization in another state and have three years of post-degree supervised experience in psychotherapy and an additional three years of post-licensure supervised experience in psychotherapy

x Treatment in a New York State Health Department-designated Comprehensive Care Center for Eating Disorders pursuant to Article 27-J of the New York State Public Health Law

x We Cover inpatient mental health care services relating to the diagnosis and treatment of mental nervous and emotional disorders received at Facilities that provide room and board charges

Whatrsquos Not Covered The following mental health care services are not covered

x Care that is not medically necessary x Out-of-network inpatient mental health care at a facility that is not an acute care general hospital x Residential treatment services

Treatment for Alcohol or Substance Abuse

Whatrsquos Covered In addition to the services listed in Your Benefits at a Glance section the following services are covered

x Family counseling services at an outpatient treatment facility These can take place before the patientrsquos treatment begins Any family member covered by the plan may receive one counseling visit per day

x Visits for family counseling are deducted from the 60 visits available for outpatient treatment x Out-of-network outpatient treatment at a facility that

Has New York State certification from the Office of Alcoholism and Substance Abuse Services Is approved by the Joint Commission on the Accreditation of Health Care Organizations if out of state The

program must offer services appropriate to the patientrsquos diagnosis

Whatrsquos Not Covered The following alcohol and substance abuse treatment services are not covered

x Out-of-network outpatient alcohol or substance abuse treatment at a facility that does not meet Empirersquos certification requirements as stated above

x Care that is not medically necessary x Out-of-network inpatient alcohol or substance abuse rehabilitation at a facility that is not an acute care general

hospital x Out-of-network inpatient detoxification at a facility that is not an acute care general hospital x Residential treatment services

30 wwwempirebluecom

Empirersquos Pharmacy Program YOUR PHARMACY BENEFITS PROGRAM

Empire understands that filling prescriptions can be costly To help reduce your costs Empire offers the pharmacy program Your Empire pharmacy program covers most drugs as long as they have been prescribed by a physician and approved by the Federal Drug Administration (FDA) You can choose whether to fill your prescription at a network pharmacy or through the mail order program

FILLING A PRESCRIPTION When you have a prescription filled you must pay the pharmacy the cost share amount for each separate prescription or refill We will pay the pharmacy directly for the remainder of the cost of the prescription or refill The Maximum Allowed Amount for covered Prescription Drugs is the amount determined by us using prescription drug cost information provided by the Pharmacy Benefits Manager (PBM) The amount of the cost share for your prescription drug coverage is listed in Your Benefits At A Glance chart

EMPIRErsquoS DRUG FORMULARY Empire uses a preferred drug formulary which is a list of generic and preferred brand drugs that is distributed to participating pharmacies and providers and is subject to periodic review and modification by Us Your doctor is encouraged to prescribe generic-equivalent drugs as appropriate when possible and to prescribe drugs from the preferred drug formulary when prescribing brand-name drugs

The Preferred Formulary has three tiers

Tier 1 drugs generally have the lowest Cost Share This tier contains preferred medications that are generic single source brand drugs or multi-source brand drugs Tier 2 drugs generally have a higher Cost Share than those in Tier 1 This tier contains preferred medications that are generic single source brand drugs or multi-source brand drugs Tier 3 drugs generally have a higher Cost Share than those on Tier 2 This tier contains non-preferred medications that are generic single source brand drugs or multi-source brand drugs

Preferred Generics For most Prescription Drugs You pay only the Cost-Sharing in the Your Benefits at a Glance section of the booklet An additional charge called an ldquoancillary chargerdquo may apply to some Prescription Drugs when a Prescription Drug on a higher tier is dispensed at You or Your Providerrsquos request and Our formulary includes a chemically equivalent Prescription Drug is available on a lower tier You will have to pay the difference between the full cost of the Prescription Drug on the higher tier and the cost of the Prescription Drug on the lower tier The cost difference is not Covered and must be paid by You in addition to the lower tier Cost-Sharing Your Cost-Sharing will never exceed the Usual and Customary Charge of the Prescription Drug Note Prescription Drugs will always be dispensed as ordered by your Doctor You may ask for or your Doctor may order the Brand Name Drug However if a Generic Drug is available you will have to pay the difference in the cost between the Generic and Brand Name Drug as well as your Tier 1 Copayment Coinsurance By law Generic and Brand Name Drugs must meet the same standards for safety strength and effectiveness Using generics generally saves money yet gives the same quality For certain higher cost generic drugs we reserve the right in our sole discretion to make an exception and not require you to pay the difference in cost between the Generic and Brand Name Drug

wwwempirebluecom 31

You are responsible for paying the full cost (the amount the pharmacy charges You) for any non-Covered Prescription Drug and Our contracted rates (Our Prescription Drug Cost) will not be available to You Tier Assignment Process Empirersquos Pharmacy and Therapeutics (PampT) Committee consists of health care professionals including nurses pharmacists and physicians The purpose of this committee is to assist in determining clinical appropriateness of drugs determining the tier assignments of drugs and advising on programs designed to help improve delivery of care Such programs may include drug utilization programs prior authorization criteria therapeutic conversion programs and drug profiling initiatives The determination of tiers is made based upon clinical decisions provided by the PampT Committee and where appropriate the cost of the Drug relative to other Drugs in its therapeutic class or used to treat the same or similar condition the availability of over-the-counter alternatives and where appropriate certain clinical economic factors Empire retains the right to determine coverage for dosage formulations in terms of covered dosage administration methods (for example by mouth injections topical or inhaled) and may cover one form of administration and exclude or place other forms of administration on another Tier The formulary and procedures are made available to all network providers at least once a year or sooner if there are changes

SPECIALTY DRUGS You or your Physician are required to order your Specialty Drugs directly from a Network Specialty Pharmacy ldquoSpecialty Drugsrdquo are prescription drugs which

x Are approved to treat limited patient populations indications or conditions x Are normally injected infused or require close monitoring by a physician or clinically trained individual or x Have limited availability special dispensing and delivery requirements andor require additional patient support any

or all of which make the drug difficult to obtain through traditional pharmacies

Network Specialty Pharmacies may fill both retail and mail service Specialty Drug prescription orders up to a thirty (30) day supply for retail and mail service and subject to the applicable Deductible Coinsurance or Copayment shown in the Your Benefits At A Glance chart

Network Specialty Pharmacies have dedicated patient care coordinators to help you obtain prior authorization if applicable manage your condition and offer toll-free twenty-four hour access to nurses and registered pharmacists to answer questions regarding your medications

You may obtain a list of the Network Specialty Pharmacies and covered Specialty Drugs by calling the Customer Service telephone number on the back of your ID card or review the lists on our website at wwwempirebluecom select ldquoPharmacyrdquo under the ldquoPlans and Benefitsrdquo tab of the ldquoMember Homerdquo page

In addition certain drugs that must be administered by a physician or other authorized practitioner are required to be ordered from our Network Specialty Pharmacy in order to be covered as a medical benefit If you require one of these drugs your physician or other treating practitioner will order the drug from the required pharmacy You will not be required to fill a prescription for this category of drug

SPECIAL PROGRAMS From time to time we may initiate various programs to encourage Covered Persons to utilize more cost-effective or clinically-effective drugs including but not limited to generic drugs mail order drugs over the counter (OTC) or preferred products Such programs may involve reducing or waiving Copayments or Coinsurance for certain drugs or preferred products for a limited period of time

REMEMBER Benefits are only available for prescriptions filled at network pharmacies or through Empirersquos mail order

NETWORK PHARMACY You must fill a prescription at an Empire network pharmacy for up to a 34-day supply of FDA-approved drugs if prescribed by a physician or other licensed provider Empirersquos pharmacy program offers

x Low cost You can receive up to a 34-day supply for each drug for a single co-payment x Convenience You must present your Empire ID card to the pharmacist along with your prescription Thatrsquos all you

need to get the cost advantages of this program x No claim forms Under your policy guidelines paper claims cannot be submitted The pharmacist must submit your

claim when you fill the prescription

32 wwwempirebluecom

Tip for Using a Network Pharmacy To locate a network pharmacy check the list of national chain pharmacies you received with your ID card For information about network pharmacies that are not a part of a national chain log on to wwwempirebluecom and click on the Rx icon on your home page or call Empirersquos pharmacy program at 1-800-342-9816 You can also call when you are away from home for the name and location of the nearest participating pharmacy

REMEMBER A pharmacist is not required to fill a prescription that in the pharmacistrsquos professional judgment should not be filled

SAVE MONEY WITH EMPIRErsquoS MAIL ORDER PRESCRIPTIONS Certain Prescription Drugs may be ordered through our mail order pharmacy You can reduce your drug co-payments by using Empirersquos pharmacy mail order because you can receive up to a 90-day (three-month) supply of your medication on a single prescription for only one co-payment This service is ideal for members who take the same medication on an on-going basis The same prescriptions filled at a participating pharmacy cost three co-payments for a three-month supply of medicationmdashone co-payment for each 34-day supply In addition Empire waives drug deductibles when you use the mail order Deductibles still apply if you fill your prescriptions at a pharmacy Home Delivery for Maintenance Medications ndash If you are taking a Maintenance Medication you may get the first 30-day supply and two 30-day refills of the same Maintenance Medication at your local Retail Pharmacy You must then contact the Home Delivery Pharmacy and tell them if you would like to keep getting your 30-day supply of Maintenance Medications from your local Retail Pharmacy or if you would like to use the Home Delivery Pharmacy You will have to pay the full retail cost of any Maintenance Medication you get without registering your choice through the Home Delivery Pharmacy You can tell us your choice by phone at the number on the back of your ID Card or by visiting our website

How to Order Your Prescription by Mail x Ask your doctor to write a prescription for each of your medication(s) that covers a 90-day supply as well as three

refills (Example If you take 2 pills per day the prescription should be written for 180 pills plus three refills) x Complete the mail order form you received in the mail with your ID card(s) You can get additional forms by going

to wwwempirebluecom or calling Empirersquos pharmacy program at the number on the back of your member ID card x Place your order for a refill at least three weeks before your current supply will run out x You will receive your filled prescription at your home within 14 working days postage paid If you prefer you can

also choose faster shipping for an additional fee

Tips for Using Mail Order The first time you fill a prescription through mail order ask your physician for a second prescription for a four-week supply You can fill the second prescription at a local pharmacy so you have the medication until the mail order is processed

MANAGE YOUR PHARMACY PLAN ONLINE Taking care of your pharmacy needs is easier than ever with Empirersquos online pharmacy If yoursquore registered for Online Member Services just go to wwwempirebluecom where you can

x Search Empirersquos drug formulary for a particular drug (by name or therapeutic category) x Locate a participating retail pharmacy near where you live or work x Order prescription refills through the mail order program x Research usage instructions drug interactions and side effects for thousands of medications

Simply log on to our web site and access your own personal secure home page Click on ldquoMy Pharmacy Planrdquo which is right next to the Rx symbol under ldquoYour Health Planrdquo

Empirersquos Pharmacy Program Customer Service 1-800-342-9816 Whatrsquos Covered The following prescription drugs are covered x Insulin and self-administered injectables x Diabetic supplies x Enteral formulas for home use that are medically

necessary and proven effective for the specific disease when prescribed by a written order by a physician or other health care provider licensed to prescribe under applicable law

x Nutritional supplements when medically necessary and proven effective for treatment

x Contraceptive drugs or devices and diaphragms x Bone mineral density drugs and devices x Refills for up to one year from the date of the original

prescription if authorized by the physician and indicated on the prescription

x Smoking cessation products by prescription only

wwwempirebluecom 33

Whatrsquos Not Covered The following items are not covered x Drugs or devices that do not require a prescription or are available over the counter except insulin and diabetic supplies x Devices of any type such as therapeutic devices IUDrsquos artificial appliances hypodermic needles syringes or similar

devices except where specifically covered and except for bone density testing and treatment devices x Charges or fees for drug administration or injection x Vitamins that by law do not require a prescription x Investigational or experimental drugs (ie medications used for experiments andor dosage levels determined by Empire

to be experimental) Refer to the Exclusions and Limitations Section and also the Complaints Appeals and Grievances Section

34 wwwempirebluecom

x Drugs received while in a hospital nursing home or other facility (covered under medical plan as indicated) x Appetite suppressants unless medically necessary x Compounded medications with no ingredients that require a prescription x Medications for cosmetic purposes only x Medications not approved by the FDA unless otherwise required by law (ie drugs that have been prescribed for the

treatment of a type of cancer for which the drug has not been approved by the FDA and not considered investigational or experimental)

x Replacement of lost stolen or damaged prescription medications x The cost for medication in excess of plan limits x Refills not dispensed in accordance with the prescription x Refills beyond one year from the original prescription date

wwwempirebluecom 35

SCHEDULE A1

Drugs Subject to Prior Authorization

Drug Class Prescription Drug

Pain Relief Abstral Arthritis Actemra Pain Relief Actiq Pulmonary Arterial Hypertension Adcirca Cancer Treatment Afinitor Psoriasis Amevive Multiple Sclerosis Ampyra Hormonal Therapy Androderm Hormonal Therapy Androgel Blood Builder Aranesp Hormonal Therapy Arixion Cancer Treatment Avastin Cervical DystoniaSpasticity Botox Immune SystemImmune Globulin Carimune NF Gaucherrsquos Disease Ceredase Gaucherrsquos Disease Cerezyme ArthritisCrohns Disease Cimzia Cervical DystoniaSpasticity Dysport Cancer Treatment Eligard ArthritisPsoriasis Enbrel Blood Builder Epogen Cancer Treatment Erbitux Arthritis Euflexxa Pain Relief Fentora Immune SystemImmune Globulin Flebogamma Pulmonary Arterial Hypertension Flolan Osteporosis Forteo Hormonal Therapy Fortesta Immune SystemImmune Globulin Gamastan Immune SystemImmune Globulin Gammagard liquid SD Immune SystemImmune Globulin Gamunex Multiple Sclerosis Gilenya Cancer Treatment Gleevac Cancer Treatment Herceptin ArthritisCrohnsPsoriasis Humira Arthritis Hyalgan Immune Deficiency Increlex Hepatitis Infergen Hepatitis Intron-A Arthritis Kineret Infection Prevention and Treatment Lamisil Blood Builder Leukine Cancer TreatmentInfertility Leuprolide Macular Degeneration Lucentis Endometriosis InfertilityCancer Lupron Depot SeizuresFibromyalgiaNerve Pain Lyrica Macular Degeneration Macugen Cervical DystoniaSpasticity Myobloc Blood Builder Neulasta Blood Builder Neumega Blood Builder Neupogen Cancer Treatment Nexavar

36 wwwempirebluecom

SCHEDULE A1 (continued)

Drugs Subject to Prior Authorization

Drug Class Prescription Drug

Excessive Sleepiness Nuvigil Immune SystemImmune Globulin Octagam Cancer Treatment Oforta Pain Relief Onsolis Arthritis Orencia Arthritis Orthovisc Immune SystemImmune Globulin Panglobulin Hepatitis Pegasys Hepatitis Peg-Intron Infection Prevention and Treatment Penlac Immune SystemImmune Globulin Polygam SD Immune SystemImmune Globulin Privigen Blood Builder Procrit Osteporosis Prolia Excessive Sleepiness Provigil Infection Prevention and Treatment Qualaquin ArthritisCrohnsPsoriasis Remicade Pulmonary Arterial Hypertension Remodulin Pulmonary Arterial Hypertension Revatio Cancer Treatment Revlimid Cancer Treatment Rituxan Hepatitis Roferon-A ArthritisPsoriasis Simponi Excessive Sleepiness Sporanox Infection Prevention and Treatment Sprycel ArthritisCrohnsPsoriasis Stelara Opiod Dependence Suboxone Arthritis Supartz Precocious Puberty Supprelin LA Cancer Treatment Sutent RSV Prevention Synagis Precocious PubertyEndometriosis Synarel Arthritis Synvisc Arthritis Synvisc One Cancer Treatment Tarceva Cancer Treatment Targretin Cancer Treatment Tasigna Cancer Treatment Temodar Hormonal Therapy Testim Cancer Treatment Thalomid Cancer Treatment Trelstar Depot LA Cancer Treatment Tykerb Pulmonary Arterial Hypertension Tyvaso Cancer Treatment Vantas Implant Cancer Treatment Vectibix Pulmonary Arterial Hypertension Ventavis Infection Prevention and Treatment Vfend Immune SystemImmune Globulin Vivaglobin Addiction Treatment Vivitrol Cancer Treatment Votrient Gaucherrsquos Disease Vpriv Cancer Treatment Xeloda

wwwempirebluecom 37

SCHEDULE A1 (continued)

Drugs Subject to Prior Authorization

Drug Class Prescription Drug

Huntingtons Disease Xenazine Bone FracturePain Due to Cancer Xgeva Arthritis Xiaflex Antibiotic Xifaxan Asthma Xolair Gaucherrsquos Disease Zavesca Cancer Treatment Zoladex Cancer Treatment Zolinza Infection Prevention and Treatment Zyvox

38 wwwempirebluecom

SCHEDULE A2

Step Therapy Drugs Subject to Prior Authorization

Drug Class Prescription Drug

Proton Pump Inhibitor Aciphex Antiacne Adoxa Antiallergy-opthalmic Alamast Non-Sedating Antihistamine Allegra ODT Suspension D Antiallergy-opthalmic Alocril Antiallergy-opthalmic Alomide Antihyperlipidemic Altoprev SedativeHypnotics Ambien CR CNS Stimulant Amphetamine Salt Combo Hypoglycemics Apidra Non-Steroidal Antiinflammatories Arthrotec Diabetes Avandament Diabetes Avandaryl Diabetes Avandia Migraine Medication Axert Diabetes Blood Glucose MetersStrips Nasal Steroids Beconase AQ Antiacne - Topical Benzaclin Multiple Sclerosis Betaseron Osteoporosis Boniva Ovulatory Stimulants Bravelle Hypoglycemics Byetta Non-Steroidal Antiinflammatories Celebrex Non-Sedating Antihistamine Clarinex-D Non-Sedating Antihistamine Clarinex Suspension Proton Pump Inhibitor Dexilant Antiacne Doryx SedativeHypnotics Edluar Antiallergy-opthalmic Elestat Dermatological Agent Elidel Antiallergy-opthalmic Emadine Overactive Bladder Agents Enablex Multiple Sclerosis Extavia Analgesics Flector Nasal Steroids Flunisolide Nasal Spray Overactive Bladder Agents Gelnique Ovulatory Stimulants Gonal-F Proton Pump Inhibitors Kapidex Antihyperlipidemic Lescol XL Antihypertensive Letairis Antihyperlipidemic Livalo Antiacne Minocin Nasal Steroids Nasacort AQ Nasal Steroids Nasarel Nasal Steroids Omnaris Antiallergy-opthalmic Optivar Overactive Bladder Agents Oxytrol Proton Pump Inhibitors pantaprazole Proton Pump Inhibitors Prilosec Proton Pump Inhibitors Prevacid Proton Pump Inhibitors Protonix Dermatological Agent Protopic

wwwempirebluecom 39

SCHEDULE A2

Step Therapy Drugs Subject to Prior Authorization (continued)

x

Drug Class Prescription Drug

Migraine Medication Relpax Nasal Steroids Rhinocort Aqua SedativeHypnotics Rozerem Antiacne Solodyn Overactive Bladder Agents Sanctura SedativeHypnotics Sonata Migraine Medication Sumavel DosePro Migraine Medication Treximet Gout Medications Uloric Hypoglycemics Victoza Antihyperlipidemics Vytorin Non-Sedating Antihistamine Xyzal Syrup Proton Pump Inhibitors Zegerid Antihyperlipidemics Zetia Skin Condition Ziana Sleep Aid Zolpimist

40 wwwempirebluecom

Exclusions and Limitations EXCLUSIONS

In addition to services mentioned under ldquoWhatrsquos Not Coveredrdquo in the prior sections your plan does not cover the following

Dental Services x Dental services including but not limited to

Cavities and extractions Care of gums Bones supporting the teeth or periodontal

abscess Orthodontia

False teeth Treatment of TMJ that is dental in nature Orthognathic surgery that is dental in nature

However your plan does cover

x Surgical removal of impacted teeth x Treatment of sound natural teeth injured by accident if treated within 12 months of the injury

ExperimentalInvestigational Treatments x Technology treatments procedures drugs biological products or medical devices that in Empirersquos judgment are

Experimental or investigative Obsolete or ineffective x Any hospitalization in connection with experimental or investigational treatments ldquoExperimentalrdquo or ldquoinvestigativerdquo

means that for the particular diagnosis or treatment of the covered personrsquos condition the treatment is Not of proven benefit Not generally recognized by the medical community (as reflected in published medical literature)

Government approval of a specific technology or treatment does not necessarily prove that it is appropriate or effective for a particular diagnosis or treatment of a covered personrsquos condition Empire may require that any or all of the following criteria be met to determine whether a technology treatment procedure biological product medical device or drug is experimental investigative obsolete or ineffective

x (FDA Approval) for the patientrsquos particular diagnosis or condition except for certain drugs prescribed for the treatment of cancer Once the FDA approves use of a medical device drug or biological product for a particular diagnosis or condition use for another diagnosis or condition may require that additional criteria be met

x Published peer review medical literature must conclude that the technology has a definite positive effect on health outcomes

x Published evidence must show that over time the treatment improves health outcomes (ie the beneficial effects outweigh any harmful effects)

x Published proof must show that the treatment at the least improves health outcomes or that it can be used in appropriate medical situations where the established treatment cannot be used Published proof must show that the treatment improves health outcomes in standard medical practice not just in an experimental laboratory setting

However your plan will cover an experimental or investigational treatment approved by an External Appeal agent certified by the state Refer to the Complaints Appeals and Grievances Section

Government Services x Services covered under government programs except Medicaid or where otherwise noted x Government hospital services except

Specific services covered in a special agreement between Empire and a government hospital United States Veteransrsquo Administration or Department of Defense Hospitals except services in connection with

a service-related disability In an emergency Empire will provide benefits until the government hospital can safely transfer the patient to a participating hospital

Home Care x Services performed at home except for those services specifically noted elsewhere in this Guide as available either at

home or as an emergency

wwwempirebluecom 41

Inappropriate Billing x Services usually given without charge even if charges are billed x Services performed by hospital or institutional staff which are billed separately from other hospital or institutional

services except as specified

Medically Unnecessary Services x Services treatment or supplies not medically necessary in Empirersquos judgment See Definitions section for more

information

Not Medically Necessary Transgender Surgery x Surgery andor treatment for gender change that does not meet our medical criteria for medical necessity

Prescription Drugs x All over the counter drugs vitamins appetite suppressants or any other type of medication unless specifically

indicated

Services Provided by a Family Member x We do not Cover services performed by a member of the covered personrsquos immediate family ldquoImmediate familyrdquo

shall mean a child spouse mother father sister or brother of You or Your Spouse

SterilizationReproductive Technologies x Reversal of sterilization x Assisted reproductive technologies including but not limited to

In-vitro fertilization Artificial insemination

Gamete and zygote intrafallopian tube transfer Intracytoplasmic sperm injection

Travel x Travel even if associated with treatment and recommended by a doctor

Vision Care x Eyeglasses contact lenses [and the examination for their fitting] except following cataract surgery unless

specifically indicated

War x Services for illness or injury received as a result of war

Workersrsquo Compensation x Services covered under Workersrsquo Compensation no-fault automobile insurance andor services covered by similar

statutory programs

LIMITATION AS INDEPENDENT CONTRACTOR The relationship between Empire BlueCross BlueShield and hospitals facilities or providers is that of independent contractors Nothing in this contract shall be deemed to create between Empire and any hospital facility or provider (or agent or employee thereof) the relationship of employer and employee or of principal and agent Empire will not be liable in any lawsuit claim or demand for damages incurred or injuries that you may sustain resulting from care received either in a hospitalfacility or from a provider

42 wwwempirebluecom

Health Management Empirersquos Medical Management Program Managing your health includes getting the information you need to make informed decisions and making sure you get the maximum benefits the plan will pay To help you manage your health Empire provides the Empirersquos Medical Management Program a service that precertifies hospital admissions and certain treatments and procedures to help ensure that you receive the highest quality of care for the right length of time in the right setting and with the maximum available coverage Empirersquos Medical Management Program works with you and your provider to help confirm the medical necessity of services and help you make sound health care decisions The program helps ensure that you and your family members receive the highest quality of care at the right time in the most appropriate setting You can contact our Medical Management program by calling the Member Services telephone number located on the back of your identification card Empire may from time to time waive enhance modify or discontinue certain medical management processes (including utilization management case management and disease management) if in Empirersquos discretion such change is in furtherance of the provision of cost effective value based andor quality services In addition we may select certain qualifying Providers to participate in a program that exempts them from certain procedural or medical management processes that would otherwise apply We may also exempt your Claim from medical review if certain conditions apply Just because Empire exempts a process Provider or Claim from the standards which otherwise would apply it does not mean that Empire will do so in the future or will do so in the future for any other Provider Claim or Member Empire may stop or modify any such exemption with or without advance notice You may determine whether a Provider is participating in certain programs by checking your on-line Provider Directory or contacting customer service number on the back of your ID card

HOW EMPIRErsquoS MEDICAL MANAGEMENT PROGRAM HELPS YOU To help ensure that you receive the maximum coverage available to you Empirersquos Medical Management Program

x Reviews all planned and emergency hospital admissions x Reviews ongoing hospitalization x Performs case management x Coordinates discharge planning x Coordinates purchase and replacement of durable medical equipment prosthetics and orthotic requirements x Reviews inpatient and ambulatory surgery x Reviews high-risk maternity admissions x Reviews care in a hospice or skilled nursing or other facility

All other services will be subject to retrospective review by our Medical Management team to determine medical necessity The health care services on the following page must be precertified with Empirersquos Medical Management Program

wwwempirebluecom 43

CALL TO PRECERTIFY THE REQUIRED SERVICEShellip

FOR ALL HOSPITAL ADMISSIONS

x At least two weeks prior to any planned surgery or hospital admission x Within 48 hours of an emergency hospital admission or as soon as reasonably possible x Of newborns for illness or injury x Before you are admitted to a rehabilitation facility or a skilled nursing facility

MATERNITY CARE

x As soon as reasonably possible we request notification within the first three months of pregnancy when possible x Within 48 hours after the actual delivery date if stay is expected to extend beyond the minimum length of stay for

mother and newborn inpatient admission forty-eight (48) hours for a vaginal birth or ninety-six (96) hours for cesarean birth

BEFORE YOU RECEIVEUSE

x Inpatient Mental Health Care Substance Abuse Care and Alcohol Detoxification x Partial Hospital Programs Psychological Testing Intensive Outpatient Programs x Occupational physical speech and vision therapy x Outpatient Ambulatory Surgical Treatments (certain procedures) x Diagnostics x Outpatient Treatments x Durable medical equipment x Air ambulance

IF SERVICES ARE NOT PRECERTIFIED If you call to precertify services as needed you will receive maximum benefits Otherwise benefits may be reduced by 50 up to $2500 for each admission treatment or procedure This benefit reduction also applies to certain same-day surgery and professional services rendered during an inpatient admission If the admission or procedure is not medically necessary no benefits will be paid

1 Preauthorization Reviews

a Non-Urgent Preauthorization Reviews If We have all the information necessary to make a determination regarding a Preauthorization review We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of receipt of the request

If We need additional information We will request it within fifteen (15) calendar days You or Your Provider will then have 45 calendar days to submit the information If We receive the requested information within 45 days We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of Our receipt of the additional information If all necessary information is not received within 45 days We will make a determination within 15 calendar days of the end of the 45 day period allowed to submit the additional information

b Urgent Preauthorization Reviews With respect to urgent Preauthorization requests if We have all

information necessary to make a determination We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within 72 hours of receipt of the request If We need additional information We will request it within 24 hours You or Your Provider will then have 48 hours to submit the information We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within 48 hours of the earlier of Our receipt of the additional information or the end of the 48-hour period allowed to submit additional information

c Court Ordered Treatment With respect to requests for mental health andor substance use disorder

services that have not yet been provided if You (or Your designee) certify in a format prescribed by the Superintendent of Financial Services that You will be appearing or have appeared before a court of competent jurisdiction and may be subject to a court order requiring such services We will make a

44 wwwempirebluecom

determination and provide notice to You (or Your designee) and Your Provider by telephone within 72 hours of receipt of the request Written notification will be provided within three (3) business days of Our receipt of the request Where feasible the telephonic and written notification will also be provided to the court

2 Concurrent Reviews

1 Non-Urgent Concurrent Reviews Utilization Review decisions for services during the course of care (concurrent reviews) will be made and notice provided to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of receipt of all necessary information If We need additional information We will request it within fifteen (15) calendar days of the receipt of the request You or Your Provider will then have 45 calendar days to submit the additional information We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of Our receipt of the additional information or if We do not receive the information within 15 calendar days of the end of the 45-day period allowed to provide the additional information

2 Urgent Concurrent Reviews For concurrent reviews that involve an extension of urgent care if the

request for coverage is made at least 24 hours prior to the expiration of a previously approved treatment We will make a determination and provide notice to You (or Your designee) and Your Provider within 24 hours of receipt of the request If the request for coverage is not made at least 24 hours prior to the expiration of a previously approved treatment We will make a determination and provide written notice to You (or Your designee) and Your Provider within 72 hours of receipt of the request If We need additional information We will request it within 24 hours You or Your Provider will then have 48 hours to submit the information We will make a determination and provide written notice to You (or Your designee) and Your Provider within the earlier of one (1) business day or 48 hours of Our receipt of the information or if We do not receive the information within 48 hours of the end of the 48-hour period

3 Inpatient Substance Use Disorder Treatment Reviews If a request for inpatient substance use disorder treatment is submitted to Us at least 24 hours prior to discharge from an inpatient substance use disorder treatment admission We will make a determination within 24 hours of receipt of the request and We will provide coverage for the inpatient substance use disorder treatment while Our determination is pending

3 Retrospective Reviews If We have all information necessary to make a determination regarding a retrospective claim We will make a determination and notify You and Your Provider within 30 calendar days of the receipt of the request If We need additional information We will request it within 30 calendar days You or Your Provider will then have 45 calendar days to provide the information We will make a determination and provide notice to You and Your Provider in writing within 15 calendar days of the earlier of Our receipt of all or part of the requested information or the end of the 45-day period

Once We have all the information to make a decision Our failure to make a Utilization Review determination within the applicable time frames set forth above will be deemed an adverse determination subject to an internal Appeal

4 Retrospective Review of Preauthorized Services We may only reverse a preauthorized treatment service

or procedure on retrospective review when x The relevant medical information presented to Us upon retrospective review is materially different

from the information presented during the Preauthorization review x The relevant medical information presented to Us upon retrospective review existed at the time of the

Preauthorization but was withheld or not made available to Us x We were not aware of the existence of such information at the time of the Preauthorization review

and x Had We been aware of such information the treatment service or procedure being requested would

not have been authorized The determination is made using the same specific standards criteria or procedures as used during the Preauthorization review

5 Reconsideration If We did not attempt to consult with Your Provider who recommended the Covered

Service before making an adverse determination the Provider may request reconsideration by the same

wwwempirebluecom 45

clinical peer reviewer who made the adverse determination or a designated clinical peer reviewer if the original clinical peer reviewer is unavailable For Preauthorization and concurrent reviews the reconsideration will take place within one (1) business day of the request for reconsideration If the adverse determination is upheld a notice of adverse determination will be given to You and Your Provider and in writing

If Empirersquos Medical Management Program does not meet the above time frames the failure should be considered a denial You or your doctor may immediately appeal

IF A REQUEST IS DENIED All denials of benefits will be rendered by qualified medical personnel If a request for care or services is denied for lack of medical necessity or because the service has been determined to be experimental or investigational Empirersquos Medical Management Program will send a notice to you and your doctor with the reasons for the denial You will have the right to appeal See section in this booklet titled ldquoComplaints Appeals and Grievancesrdquo for more information

If Empirersquos Medical Management Program denies benefits for care or services without discussing the decision with your doctor your doctor is entitled to ask Medical Management to reconsider their decision A response will be provided by telephone and in writing within one business day of making the decision

46 wwwempirebluecom

New Medical Technology REQUESTING COVERAGE

Empire uses a committee composed of Empire Medical Directors who are doctors and participating network physicians to continuously evaluate new medical technology that has not yet been designated as a covered service If you want to request certification of a new medical technology before beginning treatment your provider must contact Empirersquos Medical Management Program The provider will be asked to do the following

x Provide full supporting documentation about the new medical technology x Explain how standard medical treatment has been ineffective or would be medically inappropriate x Send us scientific peer reviewed literature that supports the effectiveness of this particular technology The literature

must not be in the form of an abstract or individual case study Empirersquos staff will evaluate the proposal in light of your contract and Empirersquos current medical policy Empire will then review the proposal taking into account relevant medical literature including current peer review articles and reviews Empire may use outside consultants if necessary If the request is complicated Empire may refer your proposal to a multi-specialty team of physicians or to a national ombudsman program designed to review such proposals Empire will send all decisions to the member andor provider

Case Management IF YOU NEED ADDITIONAL SUPPORT FOR SERIOUS ILLNESS

The Medical Management Programrsquos Case Management staff can provide assistance and support when you or a member of your family faces a chronic or catastrophic illness or injury Empirersquos nurses can help you and your family

x Find appropriate cost-effective healthcare options x Reduce medical cost x Assure quality medical care

A Case Manager serves as a single source for patient provider and insurer ndash assuring that the treatment level of care and facility are appropriate for your needs For example Case Management can help with cases such as x Cancer x Stroke x AIDS

x Chronic illness x Hemophilia x Spinal cord and other traumatic injuries

Assistance from Case Management is evaluated and provided on a case-by-case basis In some situations Empirersquos Medical Management Program staff will initiate a review of a patients health status and the attending doctors plan of care They may determine that a level of benefits not necessarily provided by this plan is desirable appropriate and cost-effective If you would like Case Management assistance following an illness or surgery contact Empirersquos Medical Management Program at 1-800-982-8089

wwwempirebluecom 47

Preventive Services Preventive Care services include Outpatient services and Office Services Screenings and other services are covered as Preventive Care for adults and children with no current symptoms or prior history of a medical condition associated with that screening or service Members who have current symptoms or have been diagnosed with a medical condition are not considered to require Preventive Care for that condition but instead benefits will be considered under the Diagnostic Services benefit Preventive Care Services in this section shall meet requirements as determined by federal law Many Preventive Care Services are covered by this Benefit Program with no Deductible Copayments or Coinsurance from the Member when provided by a Network Provider These services fall under four broad categories as shown below A Items or services with an ldquoArdquo or ldquoBrdquo rating from the United States Preventive Services Task Force

Examples of these services are screenings for Breast cancer Cervical cancer Colorectal cancer High blood pressure Type 2 diabetes mellitus Cholesterol Child and adult obesity

B Immunizations pursuant to the Advisory Committee on Immunization Practices (ldquoACIPrdquo) recommendations including

the well-child care immunizations as listed below

x DPT (diphtheria pertussis and tetanus)

x Polio

x MMR (measles mumps and rubella)

x Varicella (chicken pox)

x Hepatitis B Hemophilus

x Tetanus-diphtheria

x Pneumococcal

x Meningococcal Tetramune

x Other immunizations as determined by the Superintendent of Insurance and the Commissioner of Health in New York State or the state where your child lives

C Preventive care and screenings that are provided for in the comprehensive guidelines supported by the Health Resources

and Services Administration (ldquoHRSArdquo) including

x Well-child care visits to a pediatrician nurse or licensed nurse practitioner including a physical examination medical history developmental assessment and guidance on normal childhood development and laboratory tests The tests may be performed in the office or a laboratory Covered services and the number of visits covered per year are based on the prevailing clinical standards of the American Academy of Pediatrics (AAP) and will be determined by your childrsquos age

x Bone Density Testing and Treatment Standards for determining appropriate coverage include the criteria of the

federal Medicare program and the criteria of the National Institutes of Health for the Detection of Osteoporosis Bone mineral density measurements or tests drugs and devices include those covered under Medicare and in accordance with the criteria of the National Institutes of Health including as consistent with such criteria dual energy X-ray absorptiometry Coverage shall be available as follows

For individuals who are Ages 52 through 65 - 1 baseline Age 65 and older - 1 every 2 years (if baseline before age 65 does not indicate osteoporosis)

48 wwwempirebluecom

Under Age 65 - 1 every 2 years (if baseline before age 65 indicates osteoporosis)

For individuals who meet the criteria of the above programs including one or more of the following Previously diagnosed with or having a family history of osteoporosis Symptoms or conditions indicative of the presence or significant risk of osteoporosis Prescribed drug regimen posing a significant risk of osteoporosis Lifestyle factors to such a degree posing a significant risk of osteoporosis Age gender andor other physiological characteristics that pose a significant risk of osteoporosis

D Womenrsquos Preventive Additional preventive care and screenings for women provided for in the guidelines supported by

the Health Resources and Services Administration including the following x Well-woman care visits to a gynecologistobstetrician x Women with no prior or family history of breast cancer get a baseline mammogram between ages 35-39 and for

ages 40 and over an annual mammogram Women who have a family history of breast cancer will be covered for a routine mammogram at any age and as often as their physician recommends one

x Womenrsquos contraceptives sterilization procedures and counseling This includes contraceptive devices such as

diaphragms intra uterine devices (IUDs) and implants as well as injectable contraceptives In addition coverage is available for generic and single-source brand name prescription drugs for oral contraceptives and patches dispensed from a pharmacy To obtain benefits prescription drugs must be approved by the federal Food and Drug Administration and must be obtained from a retail or mail order pharmacy that is a member of our Pharmacy Network Please see the Oral Contraceptive Prescription Drug Rider for more information

x Breastfeeding support supplies and counseling Covered in full when received from an In-Network Provider Benefits for breast pumps are limited to one pump per Calendar Year

x Screenings andor counseling where applicable for Gestational diabetes Human Papillomavirus (HPV) sexually transmitted infections (STIs) Human immune-deficiency virus (HIV) and interpersonal and domestic violence

Screening for Prostate Cancer

We Cover an annual standard diagnostic examination including but not limited to a digital rectal examination and a prostate specific antigen test for men age 50 and over who are asymptomatic and for men age 40 and over with a family history of prostate cancer or other prostate cancer risk factors We also Cover standard diagnostic testing including but not limited to a digital rectal examination and a prostate-specific antigen test at any age for men having a prior history of prostate cancer This benefit is not subject to Copayments Deductibles or Coinsurance when provided by a Participating Provider The preventive services referenced above shall be covered in full when received from In-Network Providers Cost sharing (eg Copayments Deductibles Coinsurance) may apply to services provided during the same visit as the preventive services set forth above For example if a service referenced above is provided during an office visit wherein that service is not the primary purpose of the visit the cost-sharing amount that would otherwise apply to the office visit will still apply A list of the preventive services covered under this paragraph is available on our website at wwwempirebluecom or will be mailed to you upon request You may request the list by calling the Customer Service number on your identification card

VOLUNTARY CLINICAL QUALITY PROGRAMS The purpose of these voluntary clinical quality programs is to promote good health and early detection of disease They are designed to encourage eligible Members to obtain certain covered Preventive Care or other recommended care covered under this Certificate that was not received within the recommended timeframe For instance a program may be designed to encourage You to bring Your child to his or her PCP for a well-child or well-baby care visit if You missed a recommended check-up or may encourage You to get certain screening tests such as a mammogram if You have not been tested within the recommended age range Or a program may encourage You to have a medical visit within a specific time period such as a postpartum checkup within a set number of days after delivery of a newborn or a home visit so you can provide a blood sample for a recommended laboratory test

a Description These voluntary clinical quality programs are designed to encourage You to get certain preventive

wwwempirebluecom 49

wellness or other recommended care when You need it based on recommended clinical guidelines These programs are not guaranteed and Your participation is optional We will give You the choice and if You choose to participate in any program for which You qualify and obtain the recommended care within the programrsquos timeframe You will receive an incentive The incentive will take the form of

i a gift card in the amount of $50 or retailer coupons such as for discounts on eye glasses

ii a home test kit at no cost to allow you to conveniently collect a specimen for certain covered laboratory tests at home and mail it to the laboratory for processing In this case You may need to pay any cost shares that normally apply to covered laboratory tests under your benefit plan but the home test kit will be free to You or

iii a home visit to allow you to provide a specimen for certain covered laboratory tests or for certain biometric screenings In this care You may need to pay any cost shares that normally apply to covered laboratory tests but the home visit will be free to You

If you have any questions about whether receipt of a gift card or retailer coupon results in taxable income to You we recommend that you consult Your tax advisor

b Eligibility You the Subscriber and the Subscriberrsquos covered Spouse and each covered Dependent can

participate in the Voluntary Clinical Quality Program(s) if the targeted service applies based on the recommended clinical guidelines the program promotes These programs will be offered to Members who have certain conditions who fall within certain age ranges or who are due to receive certain recommended preventive or other care based on a recommended timeframe For example

i Members age 50-75 years who have not undergone colorectal cancer screening as recommended by the American Cancer Society may be eligible to participate in a program designed to encourage these members to obtain a recommended preventive colorectal cancer screening such as a fecal occult blood screening test

ii Members age 50-74 years who have not had a mammography screening as

recommended by the United States Preventive Services Task Force may be eligible to participate in a program designed to encourage these members to obtain the screening through the offer of a gift card awarded upon receipt of documentation that the screening was completed

c Participation If You are eligible for a clinical quality program we offer we will contact You by phone or mail to

offer You the chance to participate You may also call us at the phone number on Your ID card if You have any questions regarding program participation We will explain to You the care You are recommended to receive and the time frame within which You need to receive it to be in eligible for the reward if applicable

d Rewards Rewards for participation in a clinical quality program and completion of the identified services within the specified timeframe include monetary rewards in the form of a gift card or retailer coupon such as for discounts on eye glasses so long as the recipient is encouraged to use the reward for a product or service that promotes good health In other cases You will receive a home test kit at no cost to make it more convenient for You to receive the recommended care

50 wwwempirebluecom

Wellness Programs A Purpose The purpose of Our wellness program(s) is to encourage You to take a more active role in

managing Your health and well-being Our wellness-related programs are designed to help You achieve Your best health These programs are not Covered services under Your Plan but are separate components which are not guaranteed under Your Plan and could be discontinued at any time Participation is voluntary and You can discontinue the program at any time

B Description We provide benefits in connection with the use of or participation in any of the following wellness and health promotion actions and activities 1 Health Assessment Completion A Health Assessment is an online health tool You will answer

questions about Your lifestyle current health and history You will have access to a personal report with health tips and available online programs

x Eligibility The Subscriber and the Subscriberrsquos covered Spouse or Domestic Partner age 18 and older can participate in the program

x Participation To access the Health Assessment register or log in to Our website at wwwempirebluecom If You havenrsquot set up a user name and password select Register Now to set them up Then click on the Health amp Wellness tab and select ldquoTake my HA nowrdquo to complete the assessment On Your first visit to the site Yoursquoll be asked to give Your email address and choose health topics of interest If You do not have access to a computer please call Us at the number on Your ID card and We will provide You with information regarding how to participate without internet access We will provide You with a paper Health Assessment that will allow You to participate without computer access

2 Future Moms Future Moms is a maternity management program which provides individualized support

to expectant moms to help them achieve healthier pregnancies and deliveries The program provides education and support for high-risk and non-high-risk expectant mothers

x Eligibility The Subscriber and the Subscriberrsquos covered Spouse or Domestic Partner age 18 and older can participate in the program

x Participation Expectant moms can sign up and enroll by calling Us toll free at 800-828-5891 One of Our registered nurses will help You get started

3 Behavioral Health Resource Our Behavioral Health Resource program provides individualized support

from care managers to members with behavioral health conditions such as depression and anxiety Care managers are licensed mental health professionals whose goals are to help you take control of your health care and improve your quality of life Members have access to

x Our telephonic behavioral health resource center available 24 hours a day 7 days a week for assessment referral education coaching and crisis resolution including depression care management eating disorder management and management of other complex behavioral health concerns

x The programrsquos online and mobile app wellness tools These tools offer customized ways to address topics such as stress management anxiety depression substance abuse and chronic pain The program employs personalized tools evidence-based resources and individually-tailored eLearning programs to help members learn and practice new ways to manage their mental well-being

x Eligibility The Subscriber and each covered Dependent are eligible for the program x Participation You may call Us toll free at the number on Your ID card A care manager

will help You get started In addition We may use claims history to identify and contact potential candidates by phone to discuss whether the program is right for them

wwwempirebluecom 51

Details and Definitions In this section wersquoll cover the details you need to know to make the plan work for you Use it as a reference to understand

x Who is eligible for coverage under your plan x How to file a claim and get your benefits paid

x Your rights to appeal a claim payment or Medical Management decision

x What we mean by certain healthcare terms Knowing the details can make a difference in how satisfied you are with your plan and how easy it is for you to use If you have additional questions please visit wwwempirebluecom or call Member Services at 1-855-519-9537

Eligibility The eligibility rules and administrative procedures for adding and removing dependents for your coverage are sent out in an annually distributed official issuance of the United Nations Please do not contact Empire regarding enrollment or eligibility questions

52 wwwempirebluecom

Claims IF YOU NEED TO FILE A CLAIM

Empire makes healthcare easy by paying providers directly when you stay in-network Therefore when you receive care from providers or facilities in the Empire or BlueCard PPO networks you generally do not have to file a claim However you will have to file a claim for reimbursement for covered services received out-of-network from a non-participating provider or if you have a medical emergency out of the Empire service area To obtain a claim form call customer service

TYPE OF CLAIM IN-NETWORK OUT-OF-NETWORK

HOSPITAL Provider files claim directly with Empire or local Blue CrossBlue Shield plan

Provider files claim with Empire or local Blue CrossBlue Shield plan

MEDICAL Provider files claim directly with Empire or local Blue CrossBlue Shield plan You file claim with Empire

AMBULANCE CHARGES Provider files claim directly with Empire or local Blue CrossBlue Shield plan You file claim with Empire

At some out-of-area and non-participating hospitals you may have to pay the hospitalrsquos bill If this happens include an original itemized hospital bill with your claim

Send completed forms to

Hospital Claims

Empire BlueCross BlueShield PO Box 1407 Church Street Station New York NY 10008-1407 Attention Institutional Claims Department

Medical Claims

Empire BlueCross BlueShield PO Box 1407 Church Street Station New York NY 10008-1407 Attention Medical Claims Department

Want more claim information Now you can check the status of a claim view and print Explanation of Benefits (EOB) correct certain claim information and more at any time of day or night just by visiting wwwempirebluecom

Assignment

You authorize Empire on behalf of the Employer to make payments directly to participating In-Network Providers for Covered Services Empire also reserves the right to make payments directly to you Except where Empire expressly indicates otherwise in the case of services provided by an out of network provider payments will always be made directly to you for services provided by the out of network provider Payments may also be made to and notice regarding the receipt andor adjudication of claims an Alternate Recipient or that personrsquos custodial parent or designated representative Any payments made by Empire will discharge the Employerrsquos obligation to pay for Covered Services You cannot assign your right to receive payment to anyone else except as required by a ldquoQualified Medical Child Support orderrdquo as defined by ERISA or any applicable state or Federal law Once a Provider performs a Covered Service Empire will not honor a request to withhold payment of the claims submitted The coverage and any benefits under the Plan are not assignable by any Member without the written consent of the Plan except as provided above

wwwempirebluecom 53

Tips for Filing a Claim x File claims within 18 months of date of service x Visit wwwempirebluecom to print out a claim form immediately or contact Member Services at 1-855-519-9537

to have one mailed to you x Complete all information requested on the form x Submit all claims in English or with an English translation x Attach original bills or receipts Photocopies will not be accepted x If Empire is the secondary payer submit the original or a copy of the primary payerrsquos Explanation of Benefits (EOB)

with your itemized bill x Keep a copy of your claim form and all attachments for your records

REMEMBER File claims within 24 months of the date of service to receive benefits

IF YOU HAVE MEDICAL COVERAGE UNDER TWO PLANS (COORDINATION OF BENEFITS ndash COB) Empire has a coordination of benefits (COB) feature that applies when you and members of your family are covered under more than one health plan The benefits provided by Empire will be coordinated with any benefits you are eligible to receive under the other plan Together the plans will pay up to the amount of covered expenses but not more than the amount of actual expenses When you are covered under two plans one plan has primary responsibility to pay benefits and the other has secondary responsibility The plan with primary responsibility pays benefits first

FRAUD AND ABUSIVE BILLING We have processes to review claims before and after payment to detect fraud and abusive billing In addition We may identify certain Providers to review for potential fraud waste abuse or other inappropriate activity if the claims data suggests there may be inappropriate billing practices If a Provider is selected for review under this program then as part of the review process We may use one or more clinical utilization management guidelines in the review of claims submitted by this Provider even if those guidelines are not used for all Providers delivering services to the Planrsquos Members

Members seeking services from Non-Participating Providers could be balance billed by the Non-Participating Provider for those services that are determined to be not payable as a result of a reasonable belief of fraud or other intentional misconduct or abusive billing

Which Plan Pays Benefits First Here is how Empire determines which plan has primary responsibility for paying benefits

x If the other health plan does not have a coordination of benefits feature that plan is primary x If you are covered as an employee under the Empire plan and as a dependent under the other plan your Empire plan

is primary x For a dependent child covered under both parentsrsquo plans the primary plan is

The plan of the parent whose birthday comes earlier in the calendar year (month and day) The plan that has covered the parent for a longer period of time if the parents have the same birthday The fatherrsquos plan if the other plan does not follow the ldquobirthday rulerdquo and uses gender to determine primary

responsibility If the parents are divorced or separated (and there is no court decree establishing financial responsibility for the

childrsquos healthcare expenses) the plan covering the parent with custody is primary If the parent with custody is remarried his or her plan pays first the step-parentrsquos plan pays second and the non-

custodial parentrsquos plan pays third If the parents are divorced or separated and there is a court decree specifying which parent has financial

responsibility for the childrsquos healthcare expenses that parentrsquos plan is primary once the plan knows about the decree

x If you are actively employed your plan is primary in relation to a plan for laid-off or retired employees x If none of these rules apply the plan that has covered the patient longest is primary

If Empire Is the Secondary Plan If the Empire plan is secondary then benefits will be reduced so the total benefits paid by both plans will not be greater than the allowable expenses Also Empire will not pay more than the amount Empire would normally pay if Empire were primary

Tips for Coordinating Benefits x To receive all the benefits available to you file your claim under each plan x File claims first with the primary plan then with the secondary plan

54 wwwempirebluecom

x Include the original or a copy of the Explanation of Benefits (EOB) from the primary plan when you submit your bill to the secondary plan Remember to keep a copy for your records

If You Receive An Overpayment Of Benefits If you receive benefits that either should not have been paid or are more than should have been paid you must return any overpayment to Empire within 60 days of receiving it Overpayments include

x Payment for a service not covered by the plan x Payment for a person not covered by the plan x Payment that exceeds the amount due under your plan x Duplicate payments for the same services

Subrogation and Right of Reimbursement

These provisions apply when Plan benefits are paid as a result of injuries or illness you sustained and you have a right to a Recovery or have received a Recovery

Subrogation

The Administrator on behalf of the Employer has the right to recover Plan payments made on your behalf from any party responsible for compensating you for your injuries The following apply

x The Administrator on behalf of the Employer has the first priority for the full amount of benefits they have paid from any Recovery regardless of whether you are fully compensated and regardless of whether the payments you receive make you whole for your losses and injuries

x You and your legal representative must do whatever is necessary to enable the Administrator on behalf of the Employer to exercise their rights and do nothing to prejudice them

x The Administrator on behalf of the Employer has the right to take whatever legal action they see fit against any party or entity to recover the benefits paid under the Plan

x To the extent that the total assets from which a Recovery is available are insufficient to satisfy in full the Administrators subrogation claim and any claim still held by you The Administratorrsquos subrogation claim shall be first satisfied before any part of a Recovery is applied to your claim your attorney fees other expenses or costs

The Administrator on behalf of the Employer is not responsible for any attorney fees other expenses or costs without its prior written consent The Administrator on behalf of the Employer further agrees that the ldquocommon fundrdquo doctrine does not apply to any funds recovered by any attorney you hire regardless of whether funds recovered are used to repay benefits paid by the Administrator on behalf of the Employer

Reimbursement

If you obtain a Recovery and the Administrator on behalf of the Employer has not been repaid for the benefits the Administrator on behalf of the Employer paid on your behalf the Administrator on behalf of the Employer shall have a right to be repaid from the Recovery in the amount of the benefits paid on your behalf and the following apply

x You must reimburse the Administrator on behalf of the Employer to the extent of Plan benefits the Administrator on behalf of the Employer paid on your behalf from any Recovery

x Notwithstanding any allocation made in a settlement agreement or court order the Administrator on behalf of the Employer shall have a right of Recovery in first priority against any Recovery

x You and your legal representative must hold in trust for the Administrator on behalf of the Employer the proceeds of the gross Recovery (ie the total amount of your Recovery before attorney fees other expenses or costs) to be paid to the Administrator on behalf of the Employer immediately upon your receipt of the Recovery You must reimburse the Employer in first priority and without any set-off or reduction for attorney fees other expenses or costs The ldquocommon fundrdquo doctrine does not apply to any funds recovered by any attorney You hire regardless of whether funds recovered are used to repay benefits paid by the Administrator on behalf of the Employer

x If You fail to repay the Administrator on behalf of the Employer the Administrator on behalf of the Employer shall be entitled to deduct any of the unsatisfied portion of the amount of benefits the Administrator on behalf of the Employer has paid or the amount of your Recovery whichever is less from any future benefit under the Plan if The amount the Administrator on behalf of the Employer paid on your behalf is not repaid or otherwise

recovered by the Administrator on behalf of the Employer or You fail to cooperate

x In the event that You fail to disclose to the Administrator andor the Employer the amount of your settlement the Administrator on behalf of the Employer shall be entitled to deduct the amount of their lien from any future benefit under the Plan

wwwempirebluecom 55

x The Administrator on behalf of the Employer shall also be entitled to recover any of the unsatisfied portions of the amount they have paid or the amount of your settlement whichever is less directly from the Providers to whom the Administrator on behalf of the Employer has made payments In such a circumstance it may then be your obligation to pay the Provider the full billed amount and the Administrator on behalf of the Employer would not have any obligation to pay the Provider

The Administrator on behalf of the Employer is entitled to reimbursement from any Recovery in first priority even if the Recovery does not fully satisfy the judgment settlement or underlying claim for damages or fully compensate or make you whole

Your Duties

x You must notify the Administrator on behalf of the Employer promptly of how when and where an accident or incident resulting in personal injury or illness to you occurred and all information regarding the parties involved

x You must cooperate with the Administrator on behalf of the Employer in the investigation settlement and protection of the Employers rights of the Administrator on behalf of the Employer

x You must not do anything to prejudice the rights of the Administrator on behalf of the Employer x You must send the Administrator on behalf of the Employer copies of all police reports notices or other papers

received in connection with the accident or incident resulting in personal injury or illness to you x You must promptly notify the Administrator on behalf of the Employer if you retain an attorney or if a lawsuit is

filed on your behalf

Health Care Fraud Illegal activity adds to everyonersquos cost for healthcare Thatrsquos why Empire welcomes your help in fighting fraud If you know of any person receiving Empire benefits that they are not entitled to call us We will keep your identity confidential Want to see some recent examples of Empirersquos fraud prevention efforts Visit wwwempirebluecom

REMEMBER FRAUD HOTLINE 1-800-ICFRAUD (423-7283) During normal business hours

If You Have Questions About a Benefit Payment Empire reviews each claim for appropriate services and correct information before it is paid Once a claim is processed an Explanation of Benefits (EOB) will be sent directly to you if you have any responsibility on the claim other than your co-payment amount or if an adjustment is performed on your claim If Empire reduces or denies a claim payment you will receive a written notification or an Explanation of Benefits (EOB) citing the reasons your claim was reduced or denied The notification will give you

x The specific reason(s) for the denial x References to the pertinent plan provisions on which the denial is based x A description of any additional material or information necessary for you to establish the claim and an explanation of

why this material or information is necessary x An explanation of claims review procedures

If you have any questions about your claim your Benefits Administrator may be able to help you answer them You may also contact Empire Member Services at 1-855-519-9537 or in writing for more information When you call be sure to have your Empire ID card number handy along with any information about your claim Send written inquiries to

Empire BlueCross BlueShield PPO Member Services PO Box 1407 Church Street Station New York NY 10008-1407

56 wwwempirebluecom

Reimbursement For Covered Services Maximum Allowed Amount This section describes how We determine the amount of reimbursement for Covered Services Reimbursement for services rendered by In-Network and Out-of-Network Providers is based on the Maximum Allowed Amount for the Covered Service that you receive Please see the Blue Cross and Blue Shield Association BlueCard Program section for additional information regarding services received outside of Empirersquos service area

The Maximum Allowed Amount is the maximum amount of reimbursement Empire will pay for services and supplies

x that meet our definition of Covered Services to the extent such services and supplies are covered under Your

Plan and are not excluded x that are Medically Necessary and x that are provided in accordance with all applicable preauthorization Medical Management Programs or other

requirements set forth in Your Plan You will be required to pay a portion of the Maximum Allowed Amount to the extent you have not met your Deductible or have a Copayment or Coinsurance In addition when you receive Covered Services from an Out-of-Network Provider you may be responsible for paying any difference between the Maximum Allowed Amount and the Providerrsquos actual charges This amount can be significant

When you receive Covered Services from a Provider We will to the extent applicable apply claim processing rules to the claim submitted for those Covered Services These rules evaluate the claim information and determine among other things the appropriateness of the procedure and diagnosis codes included in the claim Applying these rules may affect our determination of the Maximum Allowed Amount Our application of these rules does not mean that the Covered Services you received were not Medically Necessary It means We have determined that the claim submitted was inconsistent with procedure coding rules andor our reimbursement policies For example your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed When this occurs the Maximum Allowed Amount will be based on the single procedure code rather than a separate Maximum Allowed Amount for each billed code Likewise when multiple procedures are performed on the same day by the same Provider or other healthcare professional We may reduce the Maximum Allowed Amounts for those secondary and subsequent procedures because reimbursement at 100 of the Maximum Allowed Amount for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive

PROVIDER NETWORK STATUS The Maximum Allowed Amount may vary depending upon whether the Provider is an In-Network Provider or an Out-of-Network Provider

For Covered Services performed by an In-Network Provider the Maximum Allowed Amount is the rate the Provider has agreed with Empire to accept as reimbursement for the Covered Services Because In-Network Providers have agreed to accept the Maximum Allowed Amount as payment in full for that service they should not send you a bill or collect for amounts above the Maximum Allowed Amount However you may receive a bill or be asked to pay all or a portion of the Maximum Allowed Amount to the extent that you have not met your Deductible or have a Copayment or Coinsurance Please call Customer Service for help in finding an In-Network Provider or visit wwwempirebluecom

Providers who have not signed any contract with Us and are not in any of our networks are Out-of-Network Providers subject to Blue Cross and Blue Shield Association rules governing claims filed by certain ancillary Providers

For Covered Services that you receive from an Out-of-Network Provider the Maximum Allowed Amount will be based on our Out-of-Network Provider fee schedulerate or the Out-of-Network Providerrsquos charge this amount is currently 275 of Medicarersquos Fee Schedule whichever is less (except Certified Social Worker 225 and Physical Therapy 200) Our Out-of-Network Provider fee schedulerate may be accessed by calling the Customer Service number on the back of your identification card The Maximum Allowed Amount on our Out-of-Network Provider fee schedulerate has been developed by reference to one or more of several sources including the following

wwwempirebluecom 57

1 Amounts based on our In-Network Provider fee schedulerate 2 Amounts based on the level andor method of reimbursement used by the Centers for Medicare and Medicaid

Services unadjusted for geographic locality for the same services or supplies Such reimbursement amounts will be updated no less than annually

3 Amounts based on charge cost reimbursement or utilization data 4 Amounts based on information provided by a third party vendor which may reflect one or more of the

following factors i) the complexity or severity of treatment ii) level of skill and experience required for the treatment or iii) comparable Providersrsquo fees and costs to deliver care or

5 An amount negotiated by the Claims Administrator or a third party vendor which has been agreed to by the Provider This may include rates for services coordinated through case management

The amount We pay a Non-Participating Provider for Emergency Services will be the greater of 1) the amount We have negotiated with Participating Providers for the Emergency Service (and if more than one amount is negotiated the median of the amounts) 2) 100 of the Allowed Amount for services provided by a Non-Participating Provider (ie the amount We would pay in the absence of any Cost-Sharing that would otherwise apply for services of Non-Participating Providers) or 3) the amount that would be paid under Medicare The amounts described above exclude any Copayment or Coinsurance that applies to Emergency Services provided by a Participating Provider For Covered Services rendered outside Empirersquos Service Area by Out-of-Network Providers claims may be priced using the local Blue Cross Blue Shield planrsquos non-participating provider fee schedule rate or the pricing arrangements required by applicable state or federal law In certain situations the Maximum Allowed Amount for out of area claims may be based on billed charges the pricing we would use if the healthcare services had been obtained within the Empire Service Area or a special negotiated price

Providers who are not contracted for this Plan but contracted for other Plans with Us are also considered Out-of-Network The Maximum Allowed Amount reimbursement for services from these Providers will be based on Our Out-of Network Provider fee schedulerate as described above unless the contract between Us and that Provider specifies a different amount

Unlike In-Network Providers Out-of-Network Providers may send you a bill and collect for the amount of the Providerrsquos charge that exceeds our Maximum Allowed Amount You are responsible for paying the difference between the Maximum Allowed Amount and the amount the Provider charges This amount can be significant Choosing an In-Network Provider will likely result in lower out of pocket costs to you Please call Customer Service for help in finding In-Network Providers or visit our website at wwwempirebluecom

Customer Service is also available to assist you in determining the Maximum Allowed Amount for a particular service from an Out-of-Network Provider In order for Us to assist you you will need to obtain from your Provider the specific procedure code(s) and diagnosis code(s) for the services the Provider will render You will also need to know the Providerrsquos charges to calculate your out of pocket responsibility Although Customer Service can assist you with this pre-service information the final Maximum Allowed Amount for your claim will be based on the actual claim submitted

MEMBER COST SHARE For certain Covered Services and depending on Your Plan you may be required to pay a part of the Maximum Allowed Amount as your cost share amount (for example Deductible Copayment andor Coinsurance)

Your cost share amount and out-of-pocket limit may vary depending on whether you received services from an In-Network or an Out-of-Network Provider Specifically you may be required to pay higher cost sharing amounts or may have limits on your benefits when using Out-of-Network Providers Please see the terms of this Benefit Booklet and Benefits At A Glance chart for your cost share amounts and limitations or call Customer Service to learn how Your Planrsquos benefits or cost share amounts may vary by the type of Provider you use

Empire will not provide any reimbursement for non-Covered Services You may be responsible for the total amount billed by your Provider for non-Covered Services regardless of whether such services are performed by an In-Network Provider or an Out-of-Network Provider Both services specifically excluded by the terms of Your Plan and those received after benefits have been exhausted are non-Covered Services Benefits may be exhausted by exceeding for example your lifetime maximum benefit caps or dayvisit limits Note that no Out-of-Network coverage is available for benefits that are listed as In-Network only in Your Plan

In some instances you may only be asked to pay the lower In-Network cost sharing amount when you use an Out-of-Network Provider For example if you go to an In-Network Hospital or Facility and receive Covered Services from an Out-of-Network

58 wwwempirebluecom

Provider such as a radiologist anesthesiologist or pathologist who is employed by or contracted with an In-Network Hospital or Facility you will pay the In-Network cost share amounts for those Covered Services However you also may be liable for the difference between the Maximum Allowed Amount and the Out-of-Network Providerrsquos charge

The following are examples for illustrative purposes only Please see Your Benefits At A Glance for Your applicable amounts

Example Your Plan has Coinsurance of 20 for In-Network services and 30 Out-of-Network after the In- or Out-of-Network Deductible has been met You undergo a surgical procedure in an In-Network Hospital The Hospital has contracted with an Out-of-Network anesthesiologist to perform the anesthesiology services for the surgery You have no control over the anesthesiologist used

The Out-of-Network anesthesiologistrsquos charge for the service is $1200 The Maximum Allowed Amount for the anesthesiology service is $950 your Coinsurance responsibility is 20 of $950 or $190 and the remaining allowance from Us is 80 of $950 or $760 You may receive a bill from the anesthesiologist for the difference between $1200 and $950 Provided the Deductible has been met your total out of pocket responsibility would be $190 (20 Coinsurance responsibility) plus an additional $250 for a total of $440 You choose an In-Network surgeon The charge is $2500 The Maximum Allowed Amount for the surgery is $1500 your Coinsurance when an In-Network surgeon is used is 20 of $1500 or $300 We allow 80 of $1500 or $1200 The In-Network surgeon accepts the total of $1500 as reimbursement for the surgery regardless of the charges Your total out of pocket responsibility would be $300 You choose an Out-of-Network surgeon The Out-of-Network surgeonrsquos charge for the service is $2500 The Maximum Allowed Amount for the surgery service is $1500 your Coinsurance for the Out-of-Network surgeon is 30 of $1500 or $450 after the Out-of-Network Deductible has been met We allow the remaining 70 of $1500 or $1050 In addition the Out-of-Network surgeon could bill you the difference between $2500 and $1500 so your total out of pocket charge would be $450 plus an additional $1000 for a total of $1450

AUTHORIZED SERVICES In some circumstances such as where there is no In-Network Provider available for the Covered Service We may authorize the In-Network cost share amounts (Deductible Copayment andor Coinsurance) to apply to a claim for a Covered Service you receive from an Out-of-Network Provider In such circumstance you must contact Us in advance of obtaining the Covered Service We will authorize the In-Network cost share amounts to apply to a claim for Covered Services if you receive Emergency services from an Out-of-Network Provider consistent with applicable state and federal regulations on Emergency Services If We authorize an Out-of-Network Covered Service so that you are responsible for the In-Network cost share amounts you may still be liable for the difference between the Maximum Allowed Amount and the Out-of-Network Providerrsquos charge Please contact Customer Service for information or to request authorization

The following are examples for illustrative purposes only Please see Your Benefits At A Glance chart for Your applicable amounts

Example You require the services of a specialist but there is no In-Network Provider for that specialty in your state of residence You contact Us in advance of receiving any Covered Services and We authorize you to go to an available Out-of-Network Provider for that Covered Service and We agree that the In-Network cost share will apply

Your Plan has a 30 Coinsurance for Out-of-Network Providers and a $25 Copayment for In-Network Providers for the Covered Service The Out-of-Network Providerrsquos charge for this service is $500 The Maximum Allowed Amount is $200

Because We have authorized the In-Network cost share amount to apply in this situation you will be responsible for the In-Network Copayment of $25 and Empire will be responsible for the remaining $175 of the $200 Maximum Allowed Amount

Because the Out-of-Network Providerrsquos charge for this service is $500 you may receive a bill from the Out-of-Network Provider for the difference between the $500 charge and the Maximum Allowed Amount of $200 Combined with your In-Network Copayment of $25 your total out of pocket expense would be $325

wwwempirebluecom 59

Complaints Appeals and Grievances Grievance Procedures A Grievances Our Grievance procedure applies to any issue not relating to a Medical Necessity or

experimental or investigational determination by Us For example it applies to contractual benefit denials or issues or concerns You have regarding Our administrative policies or access to Providers

B Filing a Grievance You can contact Us by phone at the number on Your ID card in person or in writing

to file a Grievance You may submit an oral Grievance in connection with a denial of a Referral or a covered benefit determination We may require that You sign a written acknowledgement of Your oral Grievance prepared by Us You or Your designee has up to 180 calendar days from when You received the decision You are asking Us to review to file the Grievance

When We receive Your Grievance We will mail an acknowledgment letter within 15 business days The acknowledgment letter will include the name address and telephone number of the person handling Your Grievance and indicate what additional information if any must be provided

We keep all requests and discussions confidential and We will take no discriminatory action because of Your issue We have a process for both standard and expedited Grievances depending on the nature of Your inquiry

C Grievance Determination Qualified personnel will review Your Grievance or if it is a clinical matter a

licensed certified or registered Health Care Professional will look into it We will decide the Grievance and notify You within the following timeframes

ExpeditedUrgent Grievances By phone within the earlier of 48 hours of receipt of all

necessary information or 72 hours of receipt of Your Grievance Written notice will be provided within 72 hours of receipt of Your Grievance

Pre-Service Grievances (A request for a service or treatment that has not yet been provided)

In writing within 15 calendar days of receipt of Your Grievance

Post-Service Grievances (A claim for a service or treatment that has already been provided)

In writing within 30 calendar days of receipt of Your Grievance

All Other Grievances (That are not in relation to a claim or request for a service or treatment)

In writing within 45 calendar days of receipt of all necessary information but no more than 60 calendar days of receipt of Your Grievance

D Grievance Appeals If You are not satisfied with the resolution of Your Grievance You or Your

designee may file an Appeal by phone at the number on Your ID card in person or in writing You have up to 60 business days from receipt of the Grievance determination to file an Appeal

When We receive Your Appeal We will mail an acknowledgment letter within 15 business days The acknowledgement letter will include the name address and telephone number of the person handling Your Appeal and indicate what additional information if any must be provided

One or more qualified personnel at a higher level than the personnel that rendered the Grievance determination will review it or if it is a clinical matter a clinical peer reviewer will look into it We will decide the Appeal and notify You in writing within the following timeframes

ExpeditedUrgent Grievances The earlier of two (2) business days of receipt of all

60 wwwempirebluecom

necessary information or 72 hours of receipt of Your Appeal

Pre-Service Grievances (A request for a service or treatment that has not yet been provided)

15 calendar days of receipt of Your Appeal

Post-Service Grievances (A claim for a service or treatment that has already been provided)

30 calendar days of receipt of Your Appeal

All Other Grievances (That are not in relation to a claim or request for a service or treatment)

30 business days of receipt of all necessary information to make a determination

Utilization Review 1 Utilization Review We review health services to determine whether the services are or were Medically

Necessary or experimental or investigational (Medically Necessary) This process is called Utilization Review Utilization Review includes all review activities whether they take place prior to the service being performed (Preauthorization) when the service is being performed (concurrent) or after the service is performed (retrospective) If You have any questions about the Utilization Review process please call the number on Your ID card The toll-free telephone number is available at least 40 hours a week with an after-hours answering machine

All determinations that services are not Medically Necessary will be made by 1) licensed Physicians or 2) licensed certified registered or credentialed Health Care Professionals who are in the same profession and same or similar specialty as the Provider who typically manages Your medical condition or disease or provides the health care service under review or 3) with respect to mental health or substance use disorder treatment licensed Physicians or licensed certified registered or credentialed Health Care Professionals who specialize in behavioral health and have experience in the delivery of mental health or substance use disorder courses of treatment We do not compensate or provide financial incentives to Our employees or reviewers for determining that services are not Medically Necessary We have developed guidelines and protocols to assist Us in this process For substance use disorder treatment We will use evidence-based and peer reviewed clinical review tools designated by OASAS that are appropriate to the age of the patient Specific guidelines and protocols are available for Your review upon request For more information call the number on Your ID card or visit Our website at wwwempirebluecom

2 Utilization Review Internal Appeals You Your designee and in retrospective review cases Your

Provider may request an internal Appeal of an adverse determination either by phone in person or in writing

You have up to 180 calendar days after You receive notice of the adverse determination to file an Appeal We will acknowledge Your request for an internal Appeal within 15 calendar days of receipt This acknowledgment will include the name address and phone number of the person handling Your Appeal and if necessary inform You of any additional information needed before a decision can be made The Appeal will be decided by a clinical peer reviewer who is not subordinate to the clinical peer reviewer who made the initial adverse determination and who is 1) a Physician or 2) a Health Care Professional in the same or similar specialty as the Provider who typically manages the disease or condition at issue

1 Out-of-Network Service Denial You also have the right to Appeal the denial of a Preauthorization

request for an out-of-network health service when We determine that the out-of-network health service is not materially different from an available in-network health service A denial of an out-of-network health service is a service provided by a Non-Participating Provider but only when the service is not available from a Participating Provider For a Utilization Review Appeal of denial of an out-of-network health service You or Your designee must submit

x A written statement from Your attending Physician who must be a licensed board-certified or board-eligible Physician qualified to practice in the specialty area of practice appropriate to treat Your condition that the requested out-of-network health service is materially different from the alternate health service available from a Participating Provider that We approved to treat Your condition and

wwwempirebluecom 61

x Two (2) documents from the available medical and scientific evidence that the out-of-network service 1) is likely to be more clinically beneficial to You than the alternate in-network service and 2) that the adverse risk of the out-of-network service would likely not be substantially increased over the in-network health service

2 Out-of-Network Authorization Denial You also have the right to Appeal the denial of a request for an

authorization to a Non-Participating Provider when We determine that We have a Participating Provider with the appropriate training and experience to meet Your particular health care needs who is able to provide the requested health care service For a Utilization Review Appeal of an out-of-network authorization denial You or Your designee must submit a written statement from Your attending Physician who must be a licensed board-certified or board-eligible Physician qualified to practice in the specialty area of practice appropriate to treat Your condition

x That the Participating Provider recommended by Us does not have the appropriate training and experience to meet Your particular health care needs for the health care service and

x Recommending a Non-Participating Provider with the appropriate training and experience to meet Your particular health care needs who is able to provide the requested health care service

3 First Level Appeal

1 Preauthorization Appeal If Your Appeal relates to a Preauthorization request We will decide the Appeal

within 15 calendar days of receipt of the Appeal request Written notice of the determination will be provided to You (or Your designee) and where appropriate Your Provider within two (2) business days after the determination is made but no later than 15 calendar days after receipt of the Appeal request

2 Retrospective Appeal If Your Appeal relates to a retrospective claim We will decide the Appeal within

30 calendar days of receipt of the Appeal request Written notice of the determination will be provided to You (or Your designee) and where appropriate Your Provider within two (2) business days after the determination is made but no later than 30 calendar days after receipt of the Appeal request

3 Expedited Appeal An Appeal of a review of continued or extended health care services additional

services rendered in the course of continued treatment home health care services following discharge from an inpatient Hospital admission services in which a Provider requests an immediate review mental health andor substance use disorder services that may be subject to a court order or any other urgent matter will be handled on an expedited basis An expedited Appeal is not available for retrospective reviews For an expedited Appeal Your Provider will have reasonable access to the clinical peer reviewer assigned to the Appeal within one (1) business day of receipt of the request for an Appeal Your Provider and a clinical peer reviewer may exchange information by telephone or fax An expedited Appeal will be determined within the earlier of 72 hours of receipt of the Appeal or two (2) business days of receipt of the information necessary to conduct the Appeal

If You are not satisfied with the resolution of Your expedited Appeal You may file a standard internal Appeal or an external review Our failure to render a determination of Your Appeal within 30 calendar days of receipt of the necessary information for a standard Appeal or within two (2) business days of receipt of the necessary information for an expedited Appeal will be deemed a reversal of the initial adverse determination

Substance Use Appeal If We deny a request for inpatient substance use disorder treatment that was submitted at least 24 hours prior to discharge from an inpatient admission and You or Your Provider file an expedited internal Appeal of Our adverse determination We will decide the Appeal within 24 hours of receipt of the Appeal request If You or Your Provider file the expedited internal Appeal and an expedited external review within 24 hours of receipt of Our adverse determination We will also provide coverage for the inpatient substance use disorder treatment while a determination on the internal Appeal and external review is pending

4 Second Level Appeal If You disagree with the first level Appeal determination You or Your designee can file a second level Appeal You or Your designee can also file an external review The four (4) month timeframe for filing an external review begins on receipt of the final adverse determination on the first level of Appeal By choosing to file a second level Appeal the time may expire for You to file for external review

62 wwwempirebluecom

A second level Appeal must be filed within 60 days of receipt of the final adverse determination on the first level Appeal We will acknowledge Your request for an internal Appeal within 15 calendar days of receipt This acknowledgment will include the name address and phone number of the person handling Your Appeal and inform You if necessary of any additional information needed before a decision can be made

1 Preauthorization Appeal If Your Appeal relates to a Preauthorization request We will decide the

Appeal within 15 calendar days of receipt of the Appeal request Written notice of the determination will be provided to You (or Your designee) and where appropriate Your Provider within two (2) business days after the determination is made but no later than 15 calendar days after receipt of the Appeal request

2 Retrospective Appeal If Your Appeal relates to a retrospective claim We will decide the Appeal within

30 calendar days of receipt of the Appeal request Written notice of the determination will be provided to You (or Your designee) and where appropriate Your Provider within two (2) business days after the determination is made but no later than 30 calendar days after receipt of the Appeal request

3 Expedited Appeal If Your Appeal relates to an urgent matter We will decide the Appeal and provide written notice of the determination to You (or Your designee) and where appropriate Your Provider within 72 hours of receipt of the Appeal request ]

External Review

A If the outcome of the mandatory first level appeal is adverse to you you may be eligible for an independent

External Review pursuant to federal law You must submit your request for External Review to the Claims Administrator within four (4) months of the notice of your final internal adverse determination A request for an External Review must be in writing unless the Claims Administrator determines that it is not reasonable to require a written statement You do not have to re-send the information that you submitted for internal appeal However you are encouraged to submit any additional information that you think is important for review

B For pre-service claims involving urgentconcurrent care you may proceed with an Expedited External Review without filing an internal appeal or while simultaneously pursuing an expedited appeal through our internal appeal process You or your authorized representative may request it orally or in writing All necessary information including the Claims Administratorrsquos decision can be sent between the Claims Administrator and you by telephone facsimile or other similar method To proceed with an Expedited External Review you or your authorized representative must contact the Claims Administrator at the number shown on your identification card and provide at least the following information

x the identity of the claimant x the date (s) of the medical service x the specific medical condition or symptom x the providerrsquos name x the service or supply for which approval of benefits was sought and x any reasons why the appeal should be processed on a more expedited basis

C All other requests for External Review should be submitted in writing unless the Claims Administrator

determines that it is not reasonable to require a written statement Such requests should be submitted by you or your authorized representative to

Empire Appeal and Grievance Department PO Box 1407

Church Street Station New York NY 10008-1407

This is not an additional step that you must take in order to fulfill your appeal procedure obligations described above Your decision to seek External Review will not affect your rights to any other benefits under this health care plan There is no charge for you to initiate an independent External Review The External Review decision is final and binding on all parties except for any relief available through applicable state laws or ERISA

wwwempirebluecom 63

Ending and Continuing Coverage WHEN COVERAGE ENDS

Your Empire plan coverage may terminate for any of the following reasons x Your group terminates the contract x Your employer no longer meets our underwriting standards x Your employer fails to pay premiums x You fail to pay premiums (if required) x The covered employee dies x You or your covered dependents no longer meet your employerrsquos or the contractrsquos eligibility requirements x You or your covered dependents have made a false statement on an application for coverage or on a health insurance

claim form or you or your group have otherwise engaged in fraud x Empire discontinues this class of coverage

CONTINUING COVERAGE UNDER NEW YORK STATE LAW If you are not entitled to continuation of coverage under COBRA (for example your employer has fewer than 20 employees) you may be entitled to continue coverage under New York State Law These laws vary from those under COBRA but generally also require continued coverage for up to 18 29 or 36 months Call or write to your employer or Empire to find out if you are entitled to continuation of coverage under the New York State Insurance Law

THE VETERANS BENEFITS IMPROVEMENT ACT OF 2004 The Veterans Benefits Improvement Act of 2004 which amends the 1994 Uniformed Services Employment and Reemployment Rights Act (USERRA) extends the period for continuation of health care coverage as follows

If a covered persons health plan coverage would terminate because of an absence due to military service the person may elect to continue the health plan coverage for up to 24 months after the absence begins or for the period of service Similar to COBRA the person cannot be required to pay more than 102 percent (except where State requirements provide for a lesser amount) of the full premium for the coverage If military service was for 30 or fewer days the person cannot be required to pay more than the normal employee share of any premium

ENDING AND CONTINUING COVERAGE Your EmployerPlan Sponsor reserves the right to amend or terminate its group health plan coverage provided to you at any time without prior notice or approval The decision to end or amend the health plan coverage may be due to changes in federal or state laws governing welfare benefits the requirements of the Internal Revenue Code or ERISA or any other reason

Any amendment or termination may apply to all or any portion of the group health plan coverage and to all or to only a portion of the participants and beneficiaries

Certificates of Creditable Coverage After Termination Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) a certificate of coverage must be issued to a Member and his or her covered Dependents who terminate from this Benefit Program The information included on the Certificate of Creditable Coverage will include the names of any Members terminating the date coverage under this Benefit Program ended and the type of coverage provided under this Benefit Program This Certificate of Creditable Coverage will provide a subsequent insurer or group Plan with information regarding previous coverage to assist it in determining any Pre-Existing Condition exclusion period or Affiliation Period This Certificate of Creditable Coverage should be presented by the Member to his or her next Employer Group andor when applying for subsequent group health insurance A Certificate of Creditable Coverage will be issued to terminating Members within a reasonable amount of time after Empire has terminated membership In addition a terminated Member may request an additional copy of the Certificate of Creditable Coverage by contacting Member Services

64 wwwempirebluecom

ACCESS TO INFORMATION

In addition to calling Member Services for claim and benefit information you can contact them for x The names business addresses and official positions of Empirersquos Board of Directors officers controlling persons

owners and partners x Empirersquos most recently published annual financial statement x A consumer report of grievances filed with the Insurance Superintendent x Procedures that protect confidentiality of medical records and information x A copy of Empirersquos Drug Formulary x A directory of participating providers x A description of our quality assurance program x A notice of specific individual provider affiliations with participating hospitals x Upon written request specific written clinical criteria for determining if a procedure or test is medically necessary

For Members Who Donrsquot Speak English Empire will help members who speak languages other than English ask questions and file grievances in their first language When you call Member Services the operator will link you to an interpreter in your preferred language who can facilitate the discussion 247 NurseLine is also equipped to provide assistance in most languages

wwwempirebluecom 65

Your Rights and Responsibilities

We are committed to

x Recognizing and respecting you as a member x Encouraging your open discussions with your health care professionals and providers x Providing information to help you become an informed health care consumer x Providing access to health benefits and our network providers x Sharing our expectations of you as a member

You have the right to

x Participate with your health care professionals and providers in making decisions about your health care x Receive the benefits for which you have coverage x Be treated with respect and dignity x Privacy of your personal health information consistent with state and federal laws and our policies x Receive information about our organization and services our network of health care professionals and providers

and your rights and responsibilities x Candidly discuss with your physicians and providers appropriate or medically necessary care for your condition

regardless of cost or benefit coverage x Make recommendations regarding the organizations members rights and responsibilities policies x Voice complaints or appeals about our organization any benefit or coverage decisions we (or our designated

administrators) make your coverage or care provided x Refuse treatment for any condition illness or disease without jeopardizing future treatment and be informed by

your physician(s) of the medical consequences x Participate in matters of the organizationrsquos policy and operations x The member has the right to obtain complete and current information concerning a diagnosis treatment and

prognosis from a physician or other provider in terms that the member can be reasonably expected to understand When it is not advisable to give such information to the member the information will be made available to an appropriate person acting on the members behalf

You have the responsibility to

x Choose a participating primary care physician if required by your health benefit plan x Treat all health care professionals and staff with courtesy and respect x Keep scheduled appointments with your doctor and call the doctorrsquos office if you have a delay or cancellation x Read and understand to the best of your ability all materials concerning your health benefits or ask for help if you

need it x Understand your health problems and participate along with your health care professionals and providers in

developing mutually agreed upon treatment goals to the degree possible x Supply to the extent possible information that we andor your health care professionals and providers need in order

to provide care x Follow the plans and instructions for care that you have agreed on with your health care professional and provider x Tell your health care professional and provider if you do not understand your treatment plan or what is expected of

you x Follow all health benefit plan guidelines provisions policies and procedures x Let our Customer Service Department know if you have any changes to your name address or family members

covered under your policy x Provide us with accurate and complete information needed to administer your health benefit plan including other

health benefit coverage and other insurance benefits you may have in addition to your coverage with us We are committed to providing quality benefits and customer service to our members Benefits and coverage for services provided under the benefit program are governed by the Subscriber Agreement and not by this Member Rights and Responsibilities statement

66 wwwempirebluecom

Definitions

Refer to these definitions to help you better understand your coverage Need more help Additional terms and definitions can be viewed at wwwempirebluecom

Adverse Determination A communication from Empirersquos Medical Management that reduces or denies benefits

Annual Out-of-Pocket Limit The most you pay during a Benefit Period in cost sharing before your Plan begins to pay 100 of the Maximum Allowed Amount for Covered Services The Annual Out-of-Pocket Limit does not include your Premium amounts over the Maximum Allowed Amount or charges for services that your Plan does not cover The Annual Out-of-Pocket Limit may consist of Deductibles Coinsurance andor Copayments Please see the ldquoYour Benefits At A Glancerdquo section for cost shares that apply to Your Plan

Authorized Services See ldquoprecertified servicesrdquo

Co-payment The fee you pay for office visits and certain covered services when you use in-network providers The plan then pays 100 of remaining covered expenses

Covered Services The services for which Empire provides benefits under the terms of your contract For example Empire covers one in-network annual physical exam

Deductible The dollar amount you must pay each calendar year before your plan pays benefits for covered out-of-network services If you have family coverage once the first family member meets the individual deductible the plan will pay benefits for that family member However the benefits for other family members will not be paid until two or more eligible family members meet the family deductible Once the family deductible is met your PPO plan will pay benefits for covered out-of-network services for the remainder of the year for all eligible family members The exception to this rule is a common accident benefit ndash if two or more family members are injured in the same accident and require medical care the family must meet only one individual deductible

HospitalFacility For purposes of certifying inpatient services a hospital or facility must be a fully licensed acute-care general facility that has all of the following on its own premises

x A broad scope of major surgical medical therapeutic and diagnostic services available at all times to treat almost all illnesses accidents and emergencies

x 24-hour general nursing service with registered nurses who are on duty and present in the hospital at all times x A fully-staffed operating room suitable for major surgery together with anesthesia service and equipment The

hospital must perform major surgery frequently enough to maintain a high level of expertise with respect to such surgery in order to ensure quality care

x Assigned emergency personnel and a ldquocrash cartrdquo to treat cardiac arrest and other medical emergencies x Diagnostic radiology facilities x A pathology laboratory x An organized medical staff of licensed doctors

For pregnancy and childbirth services the definition of ldquohospitalrdquo includes any birthing center that has a participation agreement with either Empire or another Blue Cross andor Blue Shield plan

For physical therapy purposes the definition of a ldquohospitalrdquo may include a rehabilitation facility either approved by Empire or participating with Empire or another Blue Cross andor Blue Shield plan other than specified above

For kidney dialysis treatment a facility in New York State qualifies for in-network benefits if the facility has an operating certificate issued by the New York State Department of Health and participates with Empire or another Blue Cross andor Blue Shield plan In other states the facility must participate with another Blue Cross andor Blue Shield plan and be certified by the state using criteria similar to New Yorkrsquos Out-of-network benefits will be paid only for non-participating facilities that have an appropriate operating certificate For behavioral healthcare purposes the definition of ldquohospitalrdquo may include a facility that has an operating certificate issued by the Commissioner of Mental Health under Article 31 of the New York Mental Hygiene Law a facility operated by the Office of Mental Health or a facility that has a participation agreement with Empire to provide mental and behavioral healthcare

wwwempirebluecom 67

services For alcohol andor substance abuse received out-of-network a facility in New York State must be certified by the Office of Alcoholism and Substance Abuse Services A facility outside of New York State must be approved by the Joint Commission on the Accreditation of Healthcare Organizations For certain specified benefits the definition of a ldquohospitalrdquo or ldquofacilityrdquo may include a hospital hospital department or facility that has a special agreement with Empire Empire does not recognize the following facilities as hospitals nursing or convalescent homes and institutions rehabilitation facilities (except as noted above) institutions primarily for rest or for the aged spas sanitariums infirmaries at schools colleges or camps

In-Network Benefits Benefits for covered services delivered by in-network providers and suppliers Services provided must fall within the scope of their individual professional licenses

In-Network ProviderSupplier A doctor other professional provider or durable medical equipment home health care or home infusion supplier who

x Is in Empirersquos PPO network x Is in the PPO network of another Blue Cross andor Blue Shield plan x Has a negotiated rate arrangement with another Blue Cross andor Blue Shield plan that does not have a PPO network

Itemized Bill A bill from a provider hospital or ambulance service that gives information that Empire needs to settle your claim Provider and hospital bills will contain the patientrsquos name diagnosis and date and charge for each service performed A provider bill will also have the providerrsquos name and address and descriptions of each service while a hospital bill will have the subscriberrsquos name and address the patientrsquos date of birth and the plan holderrsquos Empire identification number Ambulance bills will include the patientrsquos full name and address date and reason for service total mileage traveled and charges

Lifetime Maximum The maximum amount of benefits your plan will pay for covered expenses over the course of your lifetime

Maximum Allowed Amount (MAA) The maximum dollar amount of reimbursement for Covered Services Please see the Maximum Allowed Amount Reimbursement for Covered Services section for additional information

Medical Necessity We Cover benefits described in this Booklet as long as the health care service procedure treatment test device Prescription Drug or supply (collectively ldquoservicerdquo) is Medically Necessary The fact that a Provider has furnished prescribed ordered recommended or approved the service does not make it Medically Necessary or mean that We have to Cover it We may base Our decision on a review of x Your medical records x Our medical policies and clinical guidelines x Medical opinions of a professional society peer review committee or other groups of Physicians x Reports in peer-reviewed medical literature x Reports and guidelines published by nationally-recognized health care organizations that include supporting scientific data x Professional standards of safety and effectiveness which are generally-recognized in the United States for diagnosis care or

treatment x The opinion of Health Care Professionals in the generally-recognized health specialty involved x The opinion of the attending Providers which have credence but do not overrule contrary opinions Services will be deemed Medically Necessary only if x They are clinically appropriate in terms of type frequency extent site and duration and considered effective for Your

illness injury or disease x They are required for the direct care and treatment or management of that condition x Your condition would be adversely affected if the services were not provided x They are provided in accordance with generally accepted standards of medical practice x They are not primarily for the convenience of You Your family or Your Provider x They are not more costly than an alternative service of sequence of services that is at least as likely to produce equivalent

therapeutic or diagnostic results x When setting or place of service is part of the review services that can be safely provided to You in a lower cost setting will

not be Medically Necessary if they are performed in a higher cost setting For example we will not provide coverage for an inpatient admission for surgery if the surgery could have been performed on an outpatient basis or infusion of a specialty

68 wwwempirebluecom

drug provided in the outpatient department of a hospital if the drug could be provided in the physicianrsquos office of the home setting

Non-Participating HospitalFacility A hospital or facility that does not have a participation agreement with Empire or another Blue Cross andor Blue Shield plan to provide services to persons covered under Empirersquos PPO contract Or a hospital or facility that does not accept negotiated rate arrangements as payment in full in a plan area without a PPO network

Operating Area Empire operates in the following 28 eastern New York State counties Albany Bronx Clinton Columbia Delaware Dutchess Essex Fulton Greene Kings Montgomery Nassau New York Orange Putnam Queens Rensselaer Richmond Rockland Saratoga Schenectady Schoharie Suffolk Sullivan Ulster Warren Washington Westchester

Out-of-Network Benefits Reimbursement for covered services provided by out-of-network providers and suppliers Out-of-network benefits are generally subject to a deductible and coinsurance and therefore have higher out-of-pocket costs

Out-of-Network Deductible and Coinsurance Out-of-network benefits for all services are paid after you meet an individual or family out-of-network deductible Once your out-of-network deductible is met you and the plan share the cost You and the plan each pay a percentage called coinsurance of Empirersquos maximum allowed amount for the out-of-network service You are responsible for any amounts not covered or which are in excess of the allowed amount You pay your out-of-network coinsurance up to an annual out-of-pocket limit Once you meet your annual out-of-network out-of-pocket limit you will not be required to pay coinsurance but you will be responsible to pay the difference between the providerrsquos actual charge and Empirersquos allowed amount This is not applied to the deductible and coinsurance amounts Refer to Your Benefits at a Glance section for your out-of-network deductible coinsurance and out-of-pocket limit amounts

Out-of-Network ProvidersSuppliers A doctor other professional provider or durable medical equipment home health care or home infusion supplier who

x Is not in Empirersquos PPO network x Is not in the PPO network of another Blue Cross andor Blue Shield plan x Does not have a negotiated rate with another Blue Cross andor Blue Shield plan

Outpatient Surgery See ldquosame-day surgeryrdquo

Participating HospitalFacility A hospital or facility that

x Is in Empirersquos PPO network x Is in the PPO network of another Blue Cross andor Blue Shield plan x Has a negotiated rate arrangement with another Blue Cross andor Blue Shield plan that does not have a PPO network

Plan Administrator The person who has certain authority concerning the health plans such as plan management including deciding questions of eligibility for participation andor the administration of plan assets Empire is not the Plan Administrator To identify your Plan Administrator contact your employer or health plan sponsor

Precertified Services Services that must be coordinated and approved by Empirersquos Medical Management or Behavioral Healthcare Management Programs to be fully covered by your plan Failure to precertify may result in a reduction or denial of benefits

Provider A hospital or facility (as defined earlier in this section) or other appropriately licensed or certified professional healthcare practitioner Empire will pay benefits only for covered services within the scope of the practitionerrsquos license For behavioral healthcare purposes ldquoproviderrdquo includes care from psychiatrists psychologists or licensed clinical social workers providing psychiatric or psychological services within the scope of their practice including the diagnosis and treatment of mental and behavioral disorders Social workers must be licensed by the New York State Education Department or a comparable organization in another state and have three years of post-degree supervised experience in psychotherapy and an additional three years of post-licensure supervised experience in psychotherapy

wwwempirebluecom 69

For maternity care purposes ldquoproviderrdquo includes a certified nurse-midwife affiliated with or practicing in conjunction with a licensed facility and whose services are provided under qualified medical direction

Same-Day Surgery Same-day ambulatory or outpatient surgery is surgery that does not require an overnight stay in a hospital

Treatment Maximums Maximum number of treatments or visits for certain conditions Maximums for in-network and out-of-network services are combined For example if the plan has a limit of 30 visits on a covered expense you would reach the limit if you had 17 visits in-network and 13 visits out-of-network

70 wwwempirebluecom

AudioHealth Library Topics Following is a list of some of our most popular health-related audiotape topics that you can listen to free of charge 24 hours a day seven days a week when you call 247 NurseLine at 1-877-TALK-2RN (825-5276) See the 360˚ Health section for more information on the 247 NurseLine and instructions on how to listen to the tapes These are our most requested audiotapes If you do not see the topic that interests you just ask one of the NurseLine nurses

Abdominal Problems 1600 Appendicitis 1451 Constipation 1618 Crohnrsquos Disease 1260 Dehydration 1452 Diarrhea 1605 Diverticulosis and Diverticulitis 1402 Food Poisoning 1608 Gallbladder Disease 2154 Gallbladder Surgery 1612 Gastroesophageal Reflux Disease 1610 Heartburn 1952 Hepatitis 1403 Hernia 1603 Inflammatory Bowel Disease 1611 Irritable Bowel Syndrome 2576 Kidney Stones 1462 Nausea and Vomiting 1609 Rectal Problems 1613 Ulcers 2257 Urinary Incontinence in Women 1291 Urinary Tract Infections

Allergies 1000 Allergies 2770 Drug Allergies 1002 Food Allergies 1007 What About Allergy Shots

Back and Neck Pain 1450 Low Back Pain 1463 Herniated Disk 2174 Low Back Problems Surgery for 1457 Neck Pain

Bone Muscle and Joint Problems 1030 Arthritis 1780 Bunions 2103 Bursitis and Tendon Injury 1781 Calluses and Corns 2104 Carpal Tunnel Syndrome 1038 Fibromyalgia 1039 Gout 1784 Heel Spurs 1031 Juvenile Rheumatoid Arthritis 1033 Lupus

2106 Muscle Cramps and Leg Pain 2259 Osteoarthritis 1032 Osteoporosis 1034 Rheumatoid Arthritis 2169 Rotator Cuff 1456 Sports Injuries 2105 Strains Sprains Fractures and Dislocations 2151 Surgery for Carpal Tunnel Syndrome 1461 TM Disorder

Cancer 1105 Cancer Pain 1110 Colon Polyps 1113 Colorectal Cancer 1120 Womenrsquos Cancer 1124 Lung Cancer

Chest Respiratory and Circulatory Problems 1981 Asthma in Teens and Adults 1908 Atrial Fibrillation (irregular heartbeats) 1983 Bronchitis 1915 Cardiac Rehabilitation 1903 Causes of Heart Attack 1900 Chest Pain 1976 Chronic Obstructive Pulmonary Disease (COPD) 1400 Colds 1907 Heart Failure 1980 Emphysema 1455 Fever 1904 Heart Attack Prevention 1401 Influenza (Flu) 1648 Laryngitis 1910 Mitral Valve Prolapse 1911 Pacemakers 1986 Pneumonia 1406 Sinusitis 1459 Sore Throat and Strep Throat 1081 Stroke Rehabilitation 1460 Swollen Lymph Nodes 1912 Varicose Veins 1407 Viral and Bacterial Infection

wwwempirebluecom 71

Chronic Conditions 1060 ALS (Lou Gehrigrsquos Disease) 1061 Alzheimerrsquos Disease 1950 Chronic Fatigue Syndrome 2570 Chronic Kidney Disease 1063 Epilepsy 1953 Hepatitis B 1909 High Blood Pressure 1832 High Cholesterol 2623 Iron Deficiency Anemia 1959 Living with HIV Infection 1065 Multiple Sclerosis 1066 Parkinsonrsquos Disease 1512 Prediabetes 2550 Thyroid Problems 1508 Type 1 Diabetes 1500 Type 2 Diabetes 1501 Type 2 Diabetes Living with Complications 1502 Type 2 Diabetes Living with the Disease 1503 Type 2 Diabetes Recently Diagnosed

Ear Nose and Throat 1516 Diabetic Retinopathy 1453 Dizziness and Vertigo 1264 Ear Infections 1640 Earwax 1646 Hearing Loss 1641 Inner Ear Infection (Labrynthitis) 1644 Menierersquos Disease 1643 Swimmerrsquos Ear 1650 Tonsillitis

Eye Problems 1700 Eye Problems 2152 Cataract Surgery 1709 Cataracts 1710 Color Blindness 1703 Contact Lens Care 1708 Eye Infections 1705 Eye Injuries 1717 Floaters and Flashes 1712 Glaucoma 1711 Macular Degeneration 1716 Laser Surgery for Nearsightedness 1713 Strabismus 1707 Styes 1702 Vision Tests

First Aid and Emergencies 1750 Animal and Human Bites 1761 Burns 1255 Choking 1762 Cuts 2337 Frostbite 1901 Heart Attack 1759 Heat Exhaustion and Heat Stroke 2256 Hypothermia 2203 Importance of CPR Instructions 1751 Insect and Spider Bites and Stings 1458 Nosebleeds 1763 Poisoning 1764 Puncture Wounds 1766 Removing Splinters 1752 Snake Bites 1067 Stroke 1754 Tick Bites

Headaches and Nervous System Problems 1062 Bellrsquos Palsy 1515 Diabetic Neuropathy 1068 Guillain-Barre Syndrome 1064 Encephalitis 1405 Migraine Headaches 1404 Tension Headaches

Home Health Medicines and Supplies 2000 Bulking Agents and Laxatives 2007 Cold and Allergy Remedies 2003 Cough Preparations 2002 Decongestants 1270 How to Take a Temperature 2001 Pain Relievers 1758 Self-Care Supplies

Infant and Child Health 1250 ADHD 1251 Bed-wetting 2753 Bottle-feeding 1254 Chickenpox 1278 Childhood Rashes 1256 Circumcision 1257 Colic 1258 Croup 1261 Diaper Rash

72 wwwempirebluecom

Infant and Child Health

1080 Dyslexia 2436 Fetal Alcohol Syndrome 1253 Fever Age 3 and Younger 1267 Fifth Disease 1268 Growth and Development of the Newborn 1269 Hand-Foot-Mouth Disease 1837 Healthy Eating for Children 1272 Impetigo 1274 Measles 1275 Mumps 1280 Pinworms 1259 Reyersquos Syndrome 1283 Roseola

Medical Tests and Procedures 1506 Home Blood Sugar Monitoring 1532 Exercise Electrocardiography 1533 Complete Blood Count (CBC) 1534 Chest X-ray 1535 Chorionic Villus Sampling 1536 CT Scan of the Body 1537 Electroencephalogram 1538 Electrocardiogram 1539 Electromyography (EMG) 1540 Barium Enema 1541 Upper Gastrointestinal (GI) Series 1542 Magnetic Resonance Imaging 1546 Lung Function Tests

1284 Rubella (German Measles) 1287 Sudden Infant Death Syndrome (SIDS) 1288 Teething 1247 Temper Tantrums 1292 Thrush 1289 Thumb-Sucking 1290 Toilet Training 1293 Urinary Tract Infections in Children

Infectious Diseases 1408 Avian Influenza (Bird Flu) 1951 Infectious Mononucleosis 1956 Tuberculosis 1965 West Nile Virus

Living Healthy 1279 Immunizations 1295 Health Screenings 1830 Living a Balanced Lifestyle 1831 Guidelines for Eating Well 1833 Be Physically Active 1834 Healthy Weight 1835 Mind-Body Connection 1838 Alcohol and Drug Problems 1841 Be Tobacco-Free 1846 Managing Stress 1853 Healthy Snacks 1964 Relaxation Skills 2204 Accident and Injury Prevention 2428 Treatment for Alcohol Use Problems 2435 Teen Alcohol and Drug Abuse

1547 Abdominal Ultrasound 2155 Cystoscopy 2156 Dilation and Curettage 2157 Episiotomy 2158 Surgery for Hemorrhoids 2159 Hernia Surgery 2160 Hip Replacement Surgery 2162 Arthroscopy 2163 Knee Replacement Surgery 2164 Laparoscopy 2165 Ear Tubes 2171 Tonsillectomy and Adenoidectomy 2503 Shared Decisions about Surgery

Menrsquos Health 1128 Prostate Cancer 1545 Prostate-Specific Antigen Test (PSA Test) 2031 Hair Loss 2034 Benign Prostatic Hyperplasia (Enlarged Prostate) 2036 Testicular Problems 2167 TURP for BPH

wwwempirebluecom 73

Mental Health Problems and Mind-Body Wellness 1069 Bipolar Disorder 1070 Schizophrenia 1071 Dementia 1230 Domestic Violence 1240 Child Maltreatment 1845 Stress Management 2051 Obsessive-compulsive Disorder 2052 Eating Disorders 2055 Panic Attacks and Panic Disorder 2057 Depression 2059 Grief 2063 Social Anxiety Disorder 2066 Suicide

Partnership with your doctor 1201 Patients Bill of Rights 1202 Caregiver Secrets 1800 Skills for Making Wise Health Decisions 1801 Work in Partnership with your Doctor 1802 Finding a Doctor Who Will be a Partner

2352 Sunburn 2353 Warts

Sleeping Disorders 2400 Sleep Problems 2403 Sleep Apnea 2406 Snoring

Womenrsquos Health 1107 Breast Health 1111 Ovarian Cancer 1112 Polycystic Ovary Syndrome 1211 Multiple Pregnancy Twins or More 1504 Gestational Diabetes 1531 Breast Biopsy 1544 Pelvic Exam and Pap Test 1548 Ultrasound for Normal Pregnancy 2312 Pelvic Inflammatory Disease 2426 Pregnancy Precautions During 2640 Bacterial Vaginosis 2643 Yeast Infections 2650 Menopause

Senior Health 1836 Seniors Staying Active and Fit 2004 Medication Problems in Seniors 2006 Medications and Older Adults 2240 Hospice Care 2245 Care at the End of Life 2251 Nutrition for Older Adults 2261 Skin and Nail Problems in Seniors

Skin Problems 1129 Skin Cancer 1273 Lice and Scabies 1755 Blisters 1785 Ingrown Toenails 2330 Acne 2332 Boils 2333 Cold Sores 2334 Dandruff 2336 Atopic Dermatitis 2338 Hives 2343 Rashes 2344 Psoriasis 2346 Fungal Infections 2349 Shingles

2651 Hormone Therapy 2670 Missed or Irregular Periods 2672 Endometriosis 2673 Uterine Fibroids 2674 Hysterectomy 2675 Bleeding Between Periods 2677 Functional Ovarian Cysts 2678 Menstrual Cramps 2679 Dsyfuntional Uterine Bleeding 2680 Toxic Shock Syndrome 2700 How to Make a Healthy Baby 2701 Home Pregnancy Test 2704 Danger signs during pregnancy 2705 Normal Pregnancy 2706 Symptoms and Stages of Labor 2708 Diet During Pregnancy 2709 Exercise During Pregnancy 2710 Rubella and Pregnancy 2714 Amniocentesis 2717 Miscarriage 2719 Stretch Marks 2720 Cesarean Section 2723 Pelvic Organ Prolaps 2724 Premenstrual Syndrome

74 wwwempirebluecom

Womenrsquos Health 2725 Pregnancy Symptoms and Stages of 2750 Postpartum Depression 2751 Breast Feeding 2752 Complications after delivery 2754 Labor Delivery and Postpartum Period 2755 Mastitis While Breast-Feeding 2756 Rh Sensitization During Pregnancy 2757 Weaning

Additional topics that are not listed are also available

wwwempirebluecom 75

2016 AMENDMENT This Amendment changes provisions in or adds provisions to your Benefit Booklet including any affected riders endorsements or other amendments thereto issued by Empire upon your Planrsquos renewal on or after January 1 2016 Except as otherwise provided for in this Amendment the provisions herein apply to all persons covered under the Benefit Booklet (ldquoMembersrdquo) All of the terms conditions and limitations of the Benefit Booklet to which this Amendment is attached also apply to this Amendment except where they are specifically changed by this Amendment A References to ldquo360deg Healthreg Empirersquos Health Services Programsrdquo are changed to ldquoHealth and

Wellness Solutionsrdquo B The following is added to the Assignment of Benefits provision

Any purported assignment of benefits shall be void Any purported assignee of benefits shall acquire no rights by reason of any such purported assignment

C The following revisions apply to your Ambulatory Surgery benefit

a References to Ambulatory Surgery are hereby deleted and replaced with the following term

Same Day surgery Same-day or outpatient surgery is surgery performed in a hospital or other facility that does not require an overnight stay For same-day surgery the definition of ldquohospitalrdquo may include a free-standing ambulatory surgical facility that has a participation agreement with either Empire or another Blue Cross andor Blue Shield plan ldquoFacilityrdquo does not include a providerrsquos office

b i The following provision is deleted from your Benefit Booklet

You are also covered for same-day (outpatient or ambulatory) hospital services such as chemotherapy radiation therapy cardiac rehabilitation and kidney dialysis Same-day surgical services or invasive diagnostic procedures are covered when they

x Are performed in a same day or hospital outpatient surgical facility x Require the use of both surgical operating and postoperative recovery rooms x May require either local or general anesthesia x Do not require inpatient hospital admission because it is not appropriate or medically

necessary and x Would justify an inpatient hospital admission in the absence of a same-day surgery program

ii The following provision is added to your Benefit Booklet You are also covered for same-day (outpatient or ambulatory) hospital services such as chemotherapy radiation therapy cardiac rehabilitation and kidney dialysis Same-day surgical services or invasive diagnostic procedures are covered when they

x Are performed in a hospital outpatient facility x Require the use of both surgical operating and postoperative recovery rooms x May require either local or general anesthesia x Do not require inpatient hospital admission because it is not appropriate or medically

necessary and x Would justify an inpatient hospital admission in the absence of a same-day surgery program

D The following defined terms are added to your Benefit Booklet a Health Care Professional An appropriately licensed registered or certified Physician

dentist optometrist chiropractor psychologist social worker podiatrist physical therapist occupational therapist midwife speech-language pathologist audiologist pharmacist behavior analyst or any other licensed registered or certified Health Care Professional under Title 8 of the New York Education Law (or other comparable state law if applicable) that the New York Insurance Law requires to be recognized who

76 wwwempirebluecom

charges and bills patients for Covered Services The Health Care Professionalrsquos services must be rendered within the lawful scope of practice for that type of Provider in order to be covered under this benefit plan

b Provider A Physician Health Care Professional or Facility licensed registered certified or accredited as required by law A Provider also includes a vendor or dispenser of diabetic equipment and supplies durable medical equipment medical supplies or any other equipment or supplies that are Covered under this benefit plan that is licensed registered certified or accredited as required by law

wwwempirebluecom 77

2017 AMENDMENT

This Amendment changes provisions in or adds provisions to your Benefit Booklet including any affected riders endorsements or other amendments thereto issued by Empire upon your Planrsquos renewal on or after January 1 2017 Except as otherwise provided for in this Amendment the provisions herein apply to all persons covered under the Benefit Booklet (ldquoMembersrdquo) All of the terms conditions and limitations of the Benefit Booklet to which this Amendment is attached also apply to this Amendment except where they are specifically changed by this Amendment

A The following is added to the Introduction section of your Benefit Booklet Your Employer has agreed to be subject to the terms and conditions of Empirersquos provider agreements which may include precertification and utilization management requirements timely filing limits and other requirements to administer the benefits under this Plan

B The BlueCard andor Inter-Plan Program provision language is hereby deleted and

replaced with the following Inter-Plan Programs

1 Out-of-Area Services We have a variety of relationships with other Blue Cross andor Blue Shield Licensees

Generally these relationships are called ldquoInter-Plan Arrangementsrdquo These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross Blue Shield Association (ldquoAssociationrdquo) Whenever You access healthcare services outside the geographic area We serve (the ldquoEmpire Service Areardquo) the claim for those services may be processed through one of these Inter-Plan Arrangements The Inter-Plan Arrangements are described below When You receive care outside of the Empire Service Area You will receive it from one of two kinds of Providers Most Providers (ldquoParticipating Providersrdquo) contract with the local Blue Cross andor Blue Shield Plan in that geographic area (ldquoHost Bluerdquo) Some Providers (ldquoNon-Participating Providersrdquo) donrsquot contract with the Host Blue We explain below how We pay both kinds of Providers Inter-Plan Arrangements Eligibility ndash Claim Types Most claim types are eligible to be processed through Inter-Plan Arrangements as described above Examples of claims that are not included are prescription drugs that You obtain from a pharmacy and most dental or vision benefits

2 BlueCardreg Program Under the BlueCardreg Program when You receive Covered Services within the geographic area served by a Host Blue We will still fulfill Our contractual obligations But the Host Blue is responsible for (a) contracting with its Providers and (b) handling its interactions with those Providers When You receive Covered Services outside the Empire Service Area and the claim is processed through the BlueCard Program the amount You pay is calculated based on the lower of

x The billed charges for Covered Services or x The negotiated price that the Host Blue makes available to Us

Often this ldquonegotiated pricerdquo will be a simple discount that reflects an actual price that the Host Blue pays to the Provider Sometimes it is an estimated price that takes into account special arrangements with that Provider Sometimes such an arrangement may be an average price based on a discount that results in expected average savings for services provided by similar types of Providers Estimated and average pricing arrangements may also involve types of settlements incentive payments andor other credits or charges Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims as noted above However such adjustments will not affect the price We used for Your claim because they will not be applied after a claim has already been paid

3 Special Cases Value-Based Programs BlueCardreg Program If You receive Covered Services under a value-based program inside a Host Bluersquos service area You will not be responsible for paying any of the Provider Incentives risk-sharing andor Care Coordinator Fees that are a part of such an arrangement except when a Host Blue passes these fees to Empire through average pricing or fee schedule adjustments Additional information is available upon request

78 wwwempirebluecom

4 Inter-Plan Programs FederalState TaxesSurchargesFees Federal or state laws or regulations may require

a surcharge tax or other fee If applicable We will include any such surcharge tax or other fee as part of the claim charge passed on to You

5 Non-Participating Providers Outside Our Service Area a Allowed Amounts and Member Liability Calculation When Covered Services are provided outside of

Empirersquos Service Area by Non-Participating Providers We may determine benefits and make payment based on pricing from either the Host Blue or the pricing arrangements required by applicable state or federal law In these situations the amount You pay for such services as Deductible Copayment or Coinsurance will be based on that allowed amount Also You may be responsible for the difference between the amount that the Non-Participating Provider bills and the payment We will make for the Covered Services as set forth in this paragraph Federal or state law as applicable will govern payments for out-of-network emergency services

b Exceptions In certain situations We may use other pricing methods such as billed charges the pricing We would use if the healthcare services had been obtained within the Empire Service Area or a special negotiated price to determine the amount We will pay for services provided by Non-Participating Providers In these situations You may be liable for the difference between the amount that the Non-Participating Provider bills and the payment We make for the Covered Services as set forth in this paragraph

6 BlueCard Worldwidereg Program If You plan to travel outside the United States call Member Services to

find out Your BlueCard Worldwide benefits Benefits for services received outside of the United States may be different from services received in the United States Remember to take an up to date health ID card with You When You are traveling abroad and need medical care You can call the BlueCard Worldwide Service Center any time They are available 24 hours a day seven (7) days a week The toll free number is 800-810-2583 Or You can call them collect at 804-673-1177 If You need inpatient hospital care You or someone on Your behalf should contact Us for preauthorization Keep in mind if You need emergency medical care go to the nearest hospital There is no need to call before You receive care How claims are paid with BlueCard Worldwide In most cases when You arrange inpatient hospital care with BlueCard Worldwide claims will be filed for You The only amounts that You may need to pay up front are any Copayment Coinsurance or Deductible amounts that may apply You will typically need to pay for the following services up front

x Doctors services x Inpatient hospital care not arranged through BlueCard Worldwide and x Outpatient services

You will need to file a claim form for any payments made up front

When You need BlueCard Worldwide claim forms You can get international claim forms in the following ways

x Call the BlueCard Worldwide Service Center at the numbers above or x Online at wwwbluecardworldwidecom

You will find the address for mailing the claim on the form

C The Subrogation and Reimbursement provisions are hereby deleted and replaced with the following

Subrogation and Reimbursement These provisions apply when the Plan pays benefits as a result of injuries or illnesses you sustained and you have a right to a Recovery or have received a Recovery from any source A ldquoRecoveryrdquo includes but is not limited to monies received from any person or party any personrsquos or partyrsquos liability insurance uninsuredunderinsured motorist proceeds workerrsquos compensation insurance or fund ldquono-faultrdquo insurance andor automobile medical payments coverage whether by lawsuit settlement or otherwise Regardless of how

wwwempirebluecom 79

you or your representative or any agreements characterize the money you receive as a Recovery it shall be subject to these provisions 1 Subrogation

The Plan has the right to recover payments it makes on your behalf from any party responsible for compensating you for your illnesses or injuries The following apply The Plan has first priority from any Recovery for the full amount of benefits it has paid regardless of whether you are fully compensated and regardless of whether the payments you receive make you whole for your losses illnesses andor injuries You and your legal representative must do whatever is necessary to enable the Plan to exercise the Plans rights and do nothing to prejudice those rights In the event that you or your legal representative fails to do whatever is necessary to enable the Plan to exercise its subrogation rights the Plan shall be entitled to deduct the amount the Plan paid from any future benefits under the Plan The Plan has the right to take whatever legal action it sees fit against any person party or entity to recover the benefits paid under the Plan To the extent that the total assets from which a Recovery is available are insufficient to satisfy in full the Plans subrogation claim and any claim held by you the Plans subrogation claim shall be first satisfied before any part of a Recovery is applied to your claim your attorney fees other expenses or costs The Plan is not responsible for any attorney fees attorney liens other expenses or costs you incur The common fund doctrine does not apply to any funds recovered by any attorney you hire regardless of whether funds recovered are used to repay benefits paid by the Plan

2 Reimbursement

If you obtain a Recovery and the Plan has not been repaid for the benefits the Plan paid on your behalf the Plan shall have a right to be repaid from the Recovery in the amount of the benefits paid on your behalf and the following provisions will apply You must promptly reimburse the Plan from any Recovery to the extent of benefits the Plan paid on your behalf regardless of whether the payments you receive make you whole for your losses illnesses andor injuries Notwithstanding any allocation or designation of your Recovery (eg pain and suffering) made in a settlement agreement or court order the Plan shall have a right of full recovery in first priority against any Recovery Further the Planrsquos rights will not be reduced due to your negligence You and your legal representative must hold in trust for the Plan the proceeds of the gross Recovery (ie the total amount of your Recovery before attorney fees other expenses or costs) to be paid to the Plan immediately upon your receipt of the Recovery You and your legal representative acknowledge that the portion of the Recovery to which the Planrsquos equitable lien applies is a Plan asset Any Recovery you obtain must not be dissipated or disbursed until such time as the Plan has been repaid in accordance with these provisions You must reimburse the Plan in first priority and without any set-off or reduction for attorney fees other expenses or costs The common fund doctrine does not apply to any funds recovered by any attorney you hire regardless of whether funds recovered are used to repay benefits paid by the Plan If you fail to repay the Plan the Plan shall be entitled to deduct any of the unsatisfied portion of the amount of benefits the Plan has paid or the amount of your Recovery whichever is less from any future benefit under the Plan if The amount the Plan paid on your behalf is not repaid or otherwise recovered by the Plan or You fail to cooperate

80 wwwempirebluecom

In the event that you fail to disclose the amount of your settlement to the Plan the Plan shall be entitled to deduct the amount of the Planrsquos lien from any future benefit under the Plan The Plan shall also be entitled to recover any of the unsatisfied portion of the amount the Plan has paid or the amount of your Recovery whichever is less directly from the Providers to whom the Plan has made payments on your behalf In such a circumstance it may then be your obligation to pay the Provider the full billed amount and the Plan will not have any obligation to pay the Provider or reimburse you The Plan is entitled to reimbursement from any Recovery in first priority even if the Recovery does not fully satisfy the judgment settlement or underlying claim for damages or fully compensate you or make you whole

3 Your Duties

You must promptly notify the Plan of how when and where an accident or incident resulting in personal injury or illness to you occurred all information regarding the parties involved and any other information requested by the Plan You must cooperate with the Plan in the investigation settlement and protection of the Plans rights In the event that you or your legal representative fails to do whatever is necessary to enable the Plan to exercise its subrogation or reimbursement rights the Plan shall be entitled to deduct the amount the Plan paid from any future benefits under the Plan You must not do anything to prejudice the Plans rights You must send the Plan copies of all police reports notices or other papers received in connection with the accident or incident resulting in personal injury or illness to you You must promptly notify the Plan if you retain an attorney or if a lawsuit is filed on your behalf You must immediately notify the Plan if a trial is commenced if a settlement occurs or if potentially dispositive motions are filed in a case The Plan Sponsor has sole discretion to interpret the terms of the Subrogation and Reimbursement provision of this Plan in its entirety and reserves the right to make changes as it deems necessary If the covered person is a minor any amount recovered by the minor the minorrsquos trustee guardian parent or other representative shall be subject to this provision Likewise if the covered personrsquos relatives heirs andor assignees make any Recovery because of injuries sustained by the covered person that Recovery shall be subject to this provision The Plan is entitled to recover its attorneyrsquos fees and costs incurred in enforcing this provision The Plan shall be secondary in coverage to any medical payments provision no-fault automobile insurance policy or personal injury protection policy regardless of any election made by you to the contrary The Plan shall also be secondary to any excess insurance policy including but not limited to school andor athletic policies

D Provision language related to Special Enrollment Periods is hereby deleted and replaced

with the following

You Your Spouse or Child can also enroll for coverage within 60 days of the loss of coverage in another group health plan if coverage was terminated because You Your Spouse or Child are no longer eligible for coverage under the other group health plan due to

1 Termination of employment 2 Termination of the other group health plan 3 Death of the Spouse 4 Legal separation divorce or annulment 5 Reduction of hours of employment

wwwempirebluecom 81

6 Employer contributions toward the group health plan were terminated for You or Your Dependentsrsquo coverage or

7 A Child no longer qualifies for coverage as a Child under the other group health plan You Your Spouse or Child can also enroll 60 days from exhaustion of Your COBRA or continuation coverage or if You gain a Dependent or become a Dependent through marriage birth adoption or placement for adoption We must receive notice within 60 days of the loss of coverage The effective date of Your coverage will be the date indicated on the application In addition You Your Spouse or Child can also enroll for coverage within 60 days of the occurrence of one of the following events

1 You or Your Spouse or Child loses eligibility for Medicaid or a state child health plan or 2 You or Your Spouse or Child becomes eligible for Medicaid or a state child health plan

We must receive notice within 60 days of one of these events The effective date of Your coverage will be the date indicated on the application

E The following is added to the Exclusions and Limitations section of Your Benefit Booklet

x Conversion Therapy We do not cover conversion therapy Conversion therapy is any practice by a mental

health professional that seeks to change the sexual orientation or gender identity of a Member under 18 years of age including efforts to change behaviors gender expressions or to eliminate or reduce sexual or romantic attractions or feelings toward individuals of the same sex Conversion therapy does not include counseling or therapy for an individual who is seeking to undergo a gender transition or who is in the process of undergoing a gender transition that provides acceptance support and understanding of an individual or the facilitation of an individualrsquos coping social support and identity exploration and development including sexual orientation-neutral interventions to prevent or address unlawful conduct or unsafe sexual practices provided that the counseling or therapy does not seek to change sexual orientation or gender identity

82 wwwempirebluecom

2018 AMENDMENT

This Amendment changes provisions in or adds provisions to your Benefit Booklet including any affected riders endorsements or other amendments thereto issued by Empire upon your Planrsquos renewal on or after January 1 2018 Except as otherwise provided for in this Amendment the provisions herein apply to all persons covered under the Benefit Booklet (ldquoMembersrdquo) All of the terms conditions and limitations of the Benefit Booklet to which this Amendment is attached also apply to this Amendment except where they are specifically changed by this Amendment

A The following is added to the listing of services requiring prior authorization or precertification x Genetic Testing

B The BlueCard andor Inter-Plan Program provision language is hereby deleted and replaced with

the following Inter-Plan Programs 1 Out-of-Area Services We have a variety of relationships with other Blue Cross andor Blue

Shield Licensees Generally these relationships are called ldquoInter-Plan Arrangementsrdquo These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross Blue Shield Association (rdquoAssociationrdquo) Whenever You access healthcare services outside of the geographic area We serve (the ldquoEmpire Service Areardquo) the claims for these services may be processed through one of these Inter-Plan Arrangements The Inter-Plan Arrangements are described below

When You receive care outside of the Empire Service Area You will receive it from one of two kinds of Providers Most Providers (ldquoParticipating Providersrdquo) contract with the local Blue Cross andor Blue Shield Plan in that geographic area (ldquoHost Bluerdquo) Some Providers (ldquoNon-Participating Providersrdquo) donrsquot contract with the Host Blue We explain below how We pay both kinds of Providers

Inter-Plan Arrangements Eligibility ndash Claim Types Most claim types are eligible to be processed through Inter-Plan Arrangements as described above Examples of claims that are not included are prescription drugs that You obtain from a pharmacy and most dental or vision benefits

2 BlueCardreg Program Under the BlueCardreg Program when You receive Covered Services within the geographic area served by a Host Blue We will still fulfill Our contractual obligations But the Host Blue is responsible for (a) contracting with its Providers and (b) handling its interactions with those Providers

When You receive Covered Services outside the Empire Service Area and the claim is processed through the BlueCard Program the amount You pay is calculated based on the lower of

x The billed charges for Covered Services or x The negotiated price that the Host Blue makes available to Us

Often this ldquonegotiated pricerdquo will be a simple discount that reflects an actual price that the Host Blue pays to the Provider Sometimes it is an estimated price that takes into account special arrangements with that Provider Sometimes such an arrangement may be an average price based on a discount that results in expected average savings for services provided by similar types of Providers Estimated and average pricing arrangements may also involve types of settlements incentive payments andor other credits or charges Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims as noted above However such adjustments will not affect the price We used for Your claim because they will not be applied after a claim has already been paid

3 Special Cases Value-Based Programs BlueCardreg Program If You receive Covered Services under a value-based program inside a Host Bluersquos service area You will not be responsible for paying any of the Provider Incentives risk-sharing andor Care Coordinator Fees that are a part

wwwempirebluecom 83

of such an arrangement except when a Host Blue passes these fees to Empire through average pricing or fee schedule adjustments

4 Inter-Plan Programs FederalState TaxesSurchargesFees Federal or state laws or regulations may require a surcharge tax or other fee If applicable We will include any such surcharge tax or other fee as part of the claim charge passed on to You

5 Non-Participating Providers Outside Our Service Area

a Allowed Amounts and Member Liability Calculation When Covered Services are provided outside of Empirersquos Service Area by non-participating providers We may determine benefits and make payment based on pricing from either the Host Blue or the pricing arrangements required by applicable state or federal law In these situations the amount You pay for such services as Deductible Copayment or Coinsurance will be based on that allowed amount Also You may be responsible for the difference between the amount that the non-participating provider bills and the payment We will make for the Covered Services as set forth in this paragraph Federal or state law as applicable will govern payments for out-of-network emergency services

b Exceptions In certain situations We may use other pricing methods such as billed charges the pricing We would use if the healthcare services had been obtained within the Empire Service Area or a special negotiated price to determine the amount We will pay for services provided by non-participating providers In these situations You may be liable for the difference between the amount that the non-participating provider bills and the payment We make for the Covered Services as set forth in this paragraph

6 Blue Cross Blue Shield Global Corereg Program If You plan to travel outside the United States

call Member Services to find out Your Blue Cross Blue Shield Global Corereg benefits Benefits for services received outside of the United States may be different from services received in the United States The plan only covers Emergency including ambulance and Urgent Care outside of the United States Remember to take an up to date health ID card with You

When You are traveling abroad and need medical care You can call the Blue Cross Blue Shield Global Corereg Service Center any time They are available 24 hours a day seven (7) days a week The toll free number is 800-810-2583 Or You can call them collect at 804-673-1177

How claims are paid with Blue Cross Blue Shield Global Corereg In most cases when You arrange inpatient hospital care with Blue Cross Blue Shield Global Corereg claims will be filed for You The only amounts that You may need to pay up front are any Copayment Coinsurance or Deductible amounts that may apply You will typically need to pay for the following services up front x Doctors services x Inpatient hospital care not arranged through Blue Cross Blue Shield Global Corereg and x Outpatient services

You will need to file a claim form for any payments made up front

When You need Blue Cross Blue Shield Global Corereg claim forms You can get international claim forms in the following ways x Call the Blue Cross Blue Shield Global Corereg Service Center at the numbers above or x Online atwwwbcbsglobalcorecom

You will find the address for mailing the claim on the form

C The ldquoInitial Decisionsrdquo section of the ldquoHealth Managementrdquo chapter of your benefit booklet is hereby deleted and replaced with the following 5 Preauthorization Reviews

d Non-Urgent Preauthorization Reviews If We have all the information necessary to make a determination regarding a Preauthorization review We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of

84 wwwempirebluecom

receipt of the request

If We need additional information We will request it within fifteen (15) calendar days You or Your Provider will then have 45 calendar days to submit the information If We receive the requested information within 45 days We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of Our receipt of the additional information If all necessary information is not received within 45 days We will make a determination within 15 calendar days of the end of the 45 day period allowed to submit the additional information

e Urgent Preauthorization Reviews With respect to urgent Preauthorization requests if We

have all information necessary to make a determination We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within 72 hours of receipt of the request If We need additional information We will request it within 24 hours You or Your Provider will then have 48 hours to submit the information We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within 48 hours of the earlier of Our receipt of the additional information or the end of the 48-hour period allowed to submit additional information

f Court Ordered Treatment With respect to requests for mental health andor substance use

disorder services that have not yet been provided if You (or Your designee) certify in a format prescribed by the Superintendent of Financial Services that You will be appearing or have appeared before a court of competent jurisdiction and may be subject to a court order requiring such services We will make a determination and provide notice to You (or Your designee) and Your Provider by telephone within 72 hours of receipt of the request Written notification will be provided within three (3) business days of Our receipt of the request Where feasible the telephonic and written notification will also be provided to the court

6 Concurrent Reviews

4 Non-Urgent Concurrent Reviews Utilization Review decisions for services during the course of care (concurrent reviews) will be made and notice provided to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of receipt of all necessary information If We need additional information We will request it within fifteen (15) calendar days of the receipt of the request You or Your Provider will then have 45 calendar days to submit the additional information We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of Our receipt of the additional information or if We do not receive the information within 15 calendar days of the end of the 45-day period allowed to provide the additional information

5 Urgent Concurrent Reviews For concurrent reviews that involve an extension of urgent care if

the request for coverage is made at least 24 hours prior to the expiration of a previously approved treatment We will make a determination and provide notice to You (or Your designee) and Your Provider within 24 hours of receipt of the request If the request for coverage is not made at least 24 hours prior to the expiration of a previously approved treatment We will make a determination and provide written notice to You (or Your designee) and Your Provider within 72 hours of receipt of the request If We need additional information We will request it within 24 hours You or Your Provider will then have 48 hours to submit the information We will make a determination and provide written notice to You (or Your designee) and Your Provider within the earlier of one (1) business day or 48 hours of Our receipt of the information or if We do not receive the information within 48 hours of the end of the 48-hour period

6 Inpatient Substance Use Disorder Treatment Reviews If a request for inpatient substance use disorder treatment is submitted to Us at least 24 hours prior to discharge from an inpatient substance use disorder treatment admission We will make a determination within 24 hours of receipt of the request and We will provide coverage for the inpatient substance use disorder treatment while Our determination is pending

wwwempirebluecom 85

7 Retrospective Reviews If We have all information necessary to make a determination regarding a

retrospective claim We will make a determination and notify You and Your Provider within 30 calendar days of the receipt of the request If We need additional information We will request it within 30 calendar days You or Your Provider will then have 45 calendar days to provide the information We will make a determination and provide notice to You and Your Provider in writing within 15 calendar days of the earlier of Our receipt of the information or the end of the 45-day period

Once We have all the information to make a decision Our failure to make a Utilization Review determination within the applicable time frames set forth above will be deemed an adverse determination subject to an internal Appeal

8 Retrospective Review of Preauthorized Services We may only reverse a preauthorized treatment

service or procedure on retrospective review when x The relevant medical information presented to Us upon retrospective review is materially

different from the information presented during the Preauthorization review x The relevant medical information presented to Us upon retrospective review existed at the

time of the Preauthorization but was withheld or not made available to Us x We were not aware of the existence of such information at the time of the Preauthorization

review and x Had We been aware of such information the treatment service or procedure being

requested would not have been authorized The determination is made using the same specific standards criteria or procedures as used during the Preauthorization review

D Coverage for Online Visits is revised as follows

x Online visits Your coverage includes online physician office visits Covered Services

include a visit with the physician using the internet via a webcam with online chat or voice functions Services are provided by board certified licensed Primary Care Physicians Online visits are not for specialist care Common types of diagnoses and conditions treated online are cough fever headaches sore throat routine child health issues influenza upper respiratory infections sinusitis bronchitis and urinary tract infections when uncomplicated in nature Member Access To begin the online visit log on to wwwlivehealthonlinecom and establish an online account by providing some basic information about You and Your insurance plan Before You connect to a Doctor You will be asked to identify the kind of condition You want to discuss with the Doctor list Your local pharmacy provide information for the credit card You want Your cost share for the visit to be billed to agree to the terms of use and select an available Physician If You are not in New York State when You seek an online visit You will need to check to be sure an online Doctor is available in the state You are in because online Doctors are not available in every state The visit with the Physician will not start until You provide the above information and click ldquoconnectrdquo The visit will be documented in an electronic health record You may access Your records and print them and may email or fax them to Your Primary Care Physician Note about Covered Services Online visits are not meant for the following purposes

x To get reports of normal lab or other test results x To request an office appointment x To ask billing insurance coverage or payment questions x To ask for a referral to a specialist Doctor x To request Preauthorization for a benefit under your health Plan or x To ask the Physician to consult with another Physician

E The following provisions related to Claim Determinations are added to your benefit booklet

1 Claims A claim is a request that benefits or services be provided or paid according to the terms of

this Booklet When You receive services from a Participating Provider You will not need to submit a claim form However if You receive services from a Non-Participating Provider either You or the Provider must file a claim form with Us If the Non-Participating Provider is not willing to file the claim form You will need to file it with Us See the Coordination of Benefits section of this Booklet for

86 wwwempirebluecom

information on how We coordinate benefit payments when You also have health coverage with another plan

2 Notice of Claim Claims for services must include all information designated by Us as

necessary to process the claim including but not limited to Member identification number name date of birth date of service type of service the charge for each service procedure code for the service as applicable diagnosis code name and address of the Provider making the charge and supporting medical records when necessary A claim that fails to contain all necessary information will not be accepted and must be resubmitted with all necessary information Claim forms are available from Us by calling the number on Your ID card or visiting Our website at wwwempirebluecom Completed claim forms should be sent to the address in the How Your Coverage Works section of this Booklet or on Your ID card You may also submit a claim to Us electronically by sending it to the e-mail address in the How Your Coverage Works section of this Booklet on Your ID card or visiting Our website at wwwempirebluecom

3 Timeframe for Filing Claims Claims for services must be submitted to Us for payment within 18

months after You receive the services for which payment is being requested If it is not reasonably possible to submit a claim within the 18 month period You must submit it as soon as reasonably possible

4 Claims for Prohibited Referrals We are not required to pay any claim bill or other demand or

request by a Provider for clinical laboratory services pharmacy services radiation therapy services physical therapy services or x-ray or imaging services furnished pursuant to a referral prohibited by Section 238-a(1) of the New York Public Health Law

5 Claim Determinations Our claim determination procedure applies to all claims that do not relate to

a medical necessity or experimental or investigational determination For example Our claim determination procedure applies to contractual benefit denials If You disagree with Our claim determination You may submit a Grievance pursuant to the Grievance Procedures section of this Booklet

For a description of the Utilization Review procedures and Appeal process for medical necessity or experimental or investigational determinations see the Utilization Review and External Appeal sections of this Booklet

6 Pre-Service Claim Determinations

1 A pre-service claim is a request that a service or treatment be approved before it has been received If We have all the information necessary to make a determination regarding a pre-service claim (eg a covered benefit determination) We will make a determination and provide notice to You (or Your designee) within 15 days from receipt of the claim

If We need additional information We will request it within 15 days from receipt of the claim You will have 45 calendar days to submit the information If We receive the information within 45 days We will make a determination and provide notice to You (or Your designee) in writing within 15 days of Our receipt of the information If all necessary information is not received within 45 days We will make a determination within 15 calendar days of the end of the 45 day period

2 Urgent Pre-Service Reviews With respect to urgent pre-service requests if We have all

information necessary to make a determination We will make a determination and provide notice to You (or Your designee) within 72 hours of receipt of the request If We need additional information We will request it within 24 hours of receipt of the request You will then have 48 hours to submit the information We will make a determination and provide notice to You (or Your designee) within 48 hours of the earlier of Our receipt of the additional information or if information was not received at the end of the 48-hour period allowed to submit the information

7 Post-Service Claim Determinations A post-service claim is a request for a service or treatment that

You have already received If We have all information necessary to make a determination regarding a post-service claim We will make a determination and notify You (or Your designee) within 30 calendar days of the receipt of the claim If We need additional information We will request it within 30 calendar days You will then have 45 calendar days to provide the information We will make a determination and provide notice to You (or Your designee) in writing within 15 calendar days of the

wwwempirebluecom 87

earlier of Our receipt of the information or the end of the 45 day period

F The definition of ldquoProvidersrdquo is revised as follows

x For behavioral healthcare purposes ldquoproviderrdquo includes care from licensed psychiatrists or psychologists licensed clinical social workers licensed mental health counselors licensed marriage and family therapists licensed psychoanalysts licensed psychiatric nurse licensed as a nurse practitioner or clinical nurse specialist or a professional corporation or a university faculty practice corporation thereof Social workers must be licensed by the New York State Education Department or a comparable organization in another state and have three years of post-degree supervised experience in psychotherapy and an additional three years of post-licensure supervised experience in psychotherapy

88 wwwempirebluecom

Get Help In Your Language Curious to know what all this says We would be too Herersquos the English version This notice has important information about your application or benefits Look for important dates You might need to take action by certain dates to keep your benefits or manage costs You have the right to get this information and help in your language for free Call the Member Services number on your ID card for help (TTYTDD 711) Spanish Este aviso contiene informacioacuten importante acerca de su solicitud o sus beneficios Busque fechas importantes Podriacutea ser necesario que actuacutee para ciertas fechas a fin de mantener sus beneficios o administrar sus costos Tiene el derecho de obtener esta informacioacuten y ayuda en su idioma en forma gratuita Llame al nuacutemero de Servicios para Miembros que figura en su tarjeta de identificacioacuten para obtener ayuda (TTYTDD 711) Albanian Ky njoftim peumlrmban informacion teuml reumlndeumlsisheumlm rreth aplikimit ose peumlrfitimeve tuaja Shihni datat kryesore Mund trsquoju nevojitet teuml veproni brenda afateve teuml caktuara peumlr teuml vazhduar teuml peumlrfitoni ose peumlr teuml menaxhuar kostot Keni teuml drejteumln teuml merrni falas ndihmeuml dhe informacion neuml gjuheumln tuaj Peumlr ndihmeuml telefononi numrin e sheumlrbimeve peumlr aneumltareumlt teuml sheumlnuar neuml karteumln tuaj ID (TTYTDD 711) Arabic

محددة مواعید قبل إجراء اتخاذ إلى تحتاج قد المھمة المواعید تتبع على احرص لك المقدمة المزایا أو طلبك حول مھمة معلومات على الإشعار ھذا یحتوي بطاقة على الموجود الأعضاء خدمات برقم الاتصال یرجى جانام بلغتك والمساعدة المعلومات ھذه على الحصول لك یحق التكلفة لإدارة أو بالمزایا للاحتفاظ(TTYTDD711)للمساعدة بك الخاصة التعریف

Bengali আপনার আবেদন বা সবিধার বিষয়ে এই বিজঞপতিটিতে গরতবপরণ তথয রয়েছে গরতবপরণ তারিখগলির জনয দেখন আপনার সবিধাগলি বজায় রাখার জনয বা খরচ নিয়নতরণ করার জনয নিরদিষট তারিখে আপনাকে কাজ করতে হতে পারে বিনামলযে এই তথয পাওয়ার ও আপনার ভাষায় সাহাযয করার অধিকার আপনার আছে সাহাযযের জনয আপনার আইডি কারডে থাকা সদসয পরিষেবা নমবরে কল করন (TTYTDD 711) Chinese 本通知有與您的申請或利益相關的重要資訊請留意重要日期您可能需要在特定日期前採取行動以維護您的利益

或管理費用您有權使用您的語言免費獲得該資訊和協助請撥打您的 ID

卡上的成員服務號碼尋求協助(TTYTDD 711) French Cette notice contient des informations importantes sur votre demande ou votre couverture Vous y trouverez eacutegalement des dates agrave ne pas manquer Il se peut que vous deviez respecter certains deacutelais pour conserver votre couverture santeacute ou vos remboursements Vous avez le droit drsquoacceacuteder gratuitement agrave ces informations et agrave une aide dans votre langue Pour cela veuillez appeler le numeacutero des Services destineacutes aux membres qui figure sur votre carte drsquoidentification (TTYTDD 711) Greek Αυτή η ειδοποίηση περιέχει σημαντικές πληροφορίες για την εφαρμογή σας ή τις παροχές σας Αναζητήστε τις σημαντικές ημερομηνίες Ενδέχεται να χρειαστεί να κάνετε κάποιες ενέργειες μέχρι συγκεκριμένες ημερομηνίες ώστε να διατηρήσετε τις παροχές σας ή να διαχειριστείτε το κόστος Έχετε το δικαίωμα να λάβετε αυτές τις πληροφορίες και αυτήν τη βοήθεια στη γλώσσα σας δωρεάν Καλέστε τον αριθμό του Τμήματος Υπηρεσιών Μέλους (Member Services) που αναγράφεται στην ταυτότητά σας (ID card) για βοήθεια (TTYTDD 711)

wwwempirebluecom 89

Haitian Avi sa a gen enfogravemasyon enpogravetan sou aplikasyon ou an oswa avantaj ou yo Veye dat enpogravetan yo Ou ka bezwen pran aksyon avan segraveten dat pou kenbe avantaj ou yo oswa jere depans ou yo Ou gen dwa pou resevwa enfogravemasyon sa a ak asistans nan lang ou pou gratis Rele nimewo Manm Segravevis la ki sou kat idantifikasyon ou a pou jwenn egraved (TTYTDD 711) Italian Il presente avviso contiene informazioni importanti relative alla domanda da lei presentata o ai benefici a lei riservati Consulti le date importanti riportate Per continuare a usufruire dei benefici o ricevere assistenza per il pagamento delle spese potrebbe dover eseguire determinate azioni entro scadenze specifiche Ha il diritto di ricevere queste informazioni ed eventuale assistenza nella sua lingua senza alcun costo aggiuntivo Per assistenza chiami il numero dedicato ai Servizi per i membri riportato sul suo libretto (TTYTDD 711) Korean 이 공지사항에는 귀하의 신청서 또는 혜택에 대한 중요한 정보가 있습니다 중요 날짜를 살펴 보십시오 혜택을

유지하거나 비용을 관리하기 위해 특정 마감일까지 조치를 취해야 할 수 있습니다 귀하에게는 무료로 이 정보를

얻고 귀하의 언어로 도움을 받을 권리가 있습니다 도움을 얻으려면 귀하의 ID 카드에 있는 회원 서비스 번호로

전화하십시오 (TTYTDD 711) Polish Niniejsze powiadomienie zawiera istotne informacje dotyczące wniosku lub świadczeń Zwroacuteć uwagę na ważne daty Zachowanie świadczeń lub zarządzanie kosztami może wymagać podjęcia dodatkowych działań w konkretnych terminach Masz prawo do bezpłatnego otrzymania stosownych informacji oraz uzyskania pomocy w swoim języku W tym celu skontaktuj się z Działem Obsługi Klienta pod numerem telefonu podanym na karcie identyfikacyjnej (TTYTDD 711) Russian Настоящее уведомление содержит важную информацию о вашем заявлении или выплатах Обратите внимание на контрольные даты Для сохранения права на получение выплат или помощи с расходами от вас может потребоваться выполнение определенных действий в указанные сроки Вы имеете право получить данную информацию и помощь на вашем языке бесплатно Для получения помощи звоните в отдел обслуживания участников по номеру указанному на вашей идентификационной карте (TTYTDD 711) Tagalog May mahalagang impormasyon ang abisong ito tungkol sa inyong aplikasyon o mga benepisyo Tukuyin ang mahahalagang petsa Maaaring may kailangan kayong gawin sa ilang partikular na petsa upang mapanatili ang inyong mga benepisyo o mapamahalaan ang mga gastos May karapatan kayong makuha ang impormasyon at tulong na ito sa ginagamit ninyong wika nang walang bayad Tumawag sa numero ng Member Services na nasa inyong ID card para sa tulong (TTYTDD 711) Urdu

کو اپ لیے کرنےکے منظم کو لاگتوں یا فائدوں اپنے دیکھیے تاریخیں اہم ہے مشتمل پر معلومات اہم میں بارے کے فائدوں یا درخواست کی اپ نوٹس یہ ڈی ائی اپنے لیے کے مدد ہے حق کا کےحصول مدد اور معلومات ان مفت میں زبان اپنی کو اپ ہے ہوسکتی ضرورت کی کرنے اقدام پر تاریخوں بعض (TTYTDD711 )کریں کال کو نمبر سروس ممبر موجود پر کارڈ

90 wwwempirebluecom

Yiddish

מעלדונג דעם אין דאטעס נויטיגע פאר קוקט קאווערידזש אדער אפלעקאציע אייער וועגן אינפארמאציע וויכטיגע האט מעלדונג דעם האט איר קאסט מיט העלפן אדער קאווערידזש געזונט אייערע האלטן צו דעדליינז געוויסע קודם אקציע נעמען דארפן מעגליך וועט איר

קארטל אייער אויף נומער באדינונגען מעמבער די רופט בחינם שפראך אייער אין הילפט און אינפארמאציע דעם באקומען צו רעכט די(TTYTDD711)הילף פאר

Itrsquos important we treat you fairly Thatrsquos why we follow federal civil rights laws in our health programs and activities We donrsquot discriminate exclude people or treat them differently on the basis of race color national origin sex age or disability For people with disabilities we offer free aids and services For people whose primary language isnrsquot English we offer free language assistance services through interpreters and other written languages Interested in these services Call the Member Services number on your ID card for help (TTYTDD 711) If you think we failed to offer these services or discriminated based on race color national origin age disability or sex you can file a complaint also known as a grievance You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator PO Box 27401 Mail Drop VA2002-N160 Richmond VA 23279 Or you can file a complaint with the US Department of Health and Human Services Office for Civil Rights at 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 or by calling 1-800-368-1019 (TDD 1- 800-537-7697) or online at httpsocrportalhhsgovocrportallobbyjsf Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

wwwempirebluecom 3

Manage Your Healthcare Online

REGISTER NOW TO DO IT ON THE WEB

Go to wwwempirebluecom where you can securely manage your health plan 24 hours a day 7 days a week Herersquos what you can do

x Check status of claims x Search for doctors and specialists x Update your member profile x Get health information and tools with My

Health powered by WebMD

x Print plan documents x Receive information through your personal ldquoMessage Centerrdquo x Visit the Pharmacy

Plus much more hellip

HERErsquoS WHAT YOUrsquoLL NEED TO DO

All members of your family 18 or older must register separately x Go to wwwempirebluecom x Click on the Member tab and choose

ldquoRegisterrdquo

x Follow the simple registration instructions

GET PERSONALIZED HEALTH INFORMATION ndash INCLUDING YOUR HEALTH IQ

Click on MY HEALTH from your secure homepage after you register to receive the following features x Take the Health IQ test and compare your score to others in your age group x Find out how to improve your score ndash and your health ndash online x Find out how to take action against chronic and serious illnesses

Get health information for you and your family

YOUR PRIVACY IS PROTECTED

Your information is protected by one of the most advanced security methods available

Register today to experience hassle-free service wwwempirebluecom

4 wwwempirebluecom

Your PPO Guide

Introduction GETTING ANSWERS YOUR WAY 5

Using Your PPO KNOW THE BASICS 6 YOUR BENEFITS AT A GLANCE 10 DOCTORrsquoS SERVICES 17 EMERGENCY CARE 20 MATERNITY CARE 22 HOSPITAL SERVICES 23 DURABLE MEDICAL EQUIPMENT AND SUPPLIES 25 HOME HEALTH CARE 27 PHYSICAL OCCUPATIONAL SPEECH OR VISION THERAPY 28 BEHAVIORAL HEALTHCARE 29 EMPIRE PHARMACY PROGRAM 30 EXCLUSIONS AND LIMITATIONS 40

Health Management EMPIRErsquoS MEDICAL MANAGEMENT PROGRAM 42 NEW MEDICAL TECHNOLOGY 46 CASE MANAGEMENT 46 PREVENTIVE SERVICES 47 WELLNESS PROGRAMS 50

Details and Definitions ELIGIBILITY 51 CLAIMS 52 REIMBURSEMENT FOR COVERED SERVICES 56 COMPLAINTS APPEALS AND GRIEVANCES 59 ENDING AND CONTINUING COVERAGE 63 YOUR RIGHTS AND RESPONSIBILITIES 65 DEFINITIONS 66 AUDIOHEALTH LIBRARY TOPICS 70 2016 AMENDMENT 75 2017 AMENDMENT 77 2018 AMENDMENT 82 GET HELP IN YOUR LANGUAGE 88

wwwempirebluecom 5

Introduction Getting Answers Your Way Empire gives you more choices for contacting us with your customer service questions Use the Internet phone or mail to get the information you need when you need it

ON THE INTERNET Do you have customer service inquiries and need an instant response Visit wwwempirebluecom At Empire we understand that getting answers quickly is important to you Most benefit claims or membership questions can be addressed online quickly simply and confidentially Nervous about using your PC for important healthcare questions or transactions Wersquove addressed that too Just ldquosend us an e-mail

BY TELEPHONE

WHAT WHY WHERE MEMBER SERVICES For questions about your benefits claims

or membership To locate a participating behavioral healthcare provider in your area Precertification of mental health and alcoholsubstance abuse care

1-855-519-9537 TDD for hearing impaired 1-800-682-8786 830 am to 500 pm Monday ndash Friday

ATT SERVICIOS PARA IDIOMAS EXTRANJEROS

Si usted no habla ingleacutes 1-800-342-9816 Por favor permanezca en la liacutenea y espere que la grabacioacuten termine Un representante de servicios a los miembros contestaraacute la liacutenea y le conectaraacute con un traductor 900 am a 500 pm de Lunes ndash Viernes

BLUECARDreg PPO PROGRAM Get network benefits while you are away from home Locate a PPO provider outside Empirersquos network service area

1-800-810-BLUE (2583) wwwbcbscom 24 hours a day 7 days a week

MEDICAL MANAGEMENT PROGRAM Precertification of hospital admissions and certain treatments and procedures

1-855-519-9537 830 am to 500 pm Monday ndash Friday

247 NURSELINE AND AUDIOHEALTH LIBRARY

Speak with a specially trained nurse to get health information and instructions on how to listen to the tapes

1-877-TALK-2RN (825-5276) 24 hours a day 7 days a week

EMPIRErsquoS PHARMACY PROGRAM Information about the program Locate a participating retail pharmacy Obtain a complete drug formulary list

1-800-342-9816 TDD for hearing impaired 1-800-682-8786 700 am to 1000 pm Monday ndash- Friday 900 am to 900 pm Saturday 900 am to 530 pm Sunday

FRAUD HOTLINE Help prevent health insurance fraud 1-800-I-C-FRAUD (423-7283) 900 am to 500 pm Monday ndash Friday

IN WRITING Empire BlueCross BlueShield PPO Member Services PO Box 1407 Church Street Station New York NY 10008-1407

6 wwwempirebluecom

Using Your PPO

Know the Basics The key to using your PPO plan is understanding how benefits are paid Start by choosing in-network or out-of-network services any time you need healthcare Your choice determines the level of benefits you will receive

You can view and print up-to-date information about your plan or request that information be mailed to you by visiting wwwempirebluecom

CHOOSING IN-NETWORK OR OUT-OF-NETWORK SERVICES In-network services are healthcare services provided by a doctor hospital or healthcare facility that has been selected by Empire or another Blue Cross andor Blue Shield plan to provide care to our members When you choose in-network care you get these advantages

x CHOICE ndash You can choose any participating provider from the largest network of doctors and hospitals in New York State or the network of Blue Cross and Blue Shield plans through the BlueCardreg PPO Program

x FREEDOM ndash You do not need a referral to see a specialist so you direct your care x LOW COST ndash Benefits are paid after a co-payment OR deductible and coinsurance payment for office visits and

many other services x BROAD COVERAGE ndash Benefits are available for a broad range of healthcare services including visits to specialists

physical therapy and home health care x CONVENIENCE ndash Usually there are no claim forms to file x Out-of-network services are healthcare services provided by a licensed provider outside Empirersquos PPO network or the

BlueCard PPO networks of other Blue Cross andor Blue Shield plans For most services you can choose in-network or out-of-network However some services are only available in-network When you use out-of-network services You pay an annual deductible and coinsurance plus any amount above the maximum allowed amount (the

maximum Empire will pay for a covered service) This amount is currently 275 of Medicarersquos Fee Schedule (except for physical therapy services which is 200 of Medicarersquos Fee Schedule and Certified Social Worker which is 225 of Medicarersquos Fee Schedule) if you use a BlueCard provider you will pay only the lower of billed charges or a negotiated rate and your member liability

You will usually have to pay the provider when you receive care You will need to file a claim to be reimbursed by Empire

wwwempirebluecom 7

The following chart shows your specific plan information as of July 1 2013 See the Details and Definitions section for explanations of terms in the chart

IN-NETWORK OUT-Of-NETWORK

ANNUAL DEDUCTIBLE $0 $250Individual $750Family

CO-PAYMENT (for office visits and certain covered services)

$15 per visit (Non-Specialist)

$20 per visit (Specialist)

NA

CO-PAYMENT (for hospital inpatient admissions)

$0 NA

CO-PAYMENT (for emergency room) $75 per visit (waived if admitted to hospital within 24 hours)

$75 per visit (waived if admitted to hospital within 24 hours)

COINSURANCE NA You pay 20 of allowed amount Plan pays 80 of maximum allowed amount

ANNUAL OUT-OF-POCKET LIMIT

(includes Deductible Coinsurance Copayments and cost sharing for Prescription drug coverage)

NA $1250Individual $3250Family

LIFETIME MAXIMUM Unlimited Unlimited

COST SHARE CREDIT If on the day before the effective date of this benefit booklet a member was covered under a group major medical or extended medical contract issued to your group by us or another carrier any covered expenses applied to the in-network and out-of-network deductible and in-network and out-of-network out-of-pocket limit incurred by the member under the prior group contract during the same benefit period will be applied to the satisfaction of any in-network and out-of-network deductible and in-network and out-of-network out-of-pocket limit required under this benefit booklet during the same benefit period for such member for that year only This applies only to members who are covered on the initial effective date of the new benefit booklet with us

HOW TO ACCESS PRIMARY AND SPECIALTY CARE SERVICES Your health plan covers certain primary and specialty care services To access primary care services simply visit any network physician who is a general or family practitioner internist or pediatrician Your health plan covers care provided by any network specialty care provider you choose Referrals are never needed to visit any network specialty care provider To make an appointment call your physicianrsquos office

x Tell them you are an Empire member x Have your Member ID card handy They may ask you for your group number member ID number or

office visit copay x Tell them the reason for your visit

When you go for your appointment take your Member ID card

WHEN YOU NEED CARE AFTER NORMAL OFFICE HOURS After hours care is provided by your physician who may have a variety of ways of addressing your needs Call your physician for instructions on how to receive medical care after their normal business hours on weekends and holidays This includes information about how to receive non-Emergency Care and non-Urgent Care within the service area for a condition that is not life threatening but that requires prompt medical attention If you have an emergency call 911 or go to the nearest emergency room

8 wwwempirebluecom

WHERE TO FIND NETWORK PROVIDERS Empirersquos PPO network gives you access to providers within the planrsquos operating area of 28 eastern New York State counties See ldquooperating areardquo in the Details and Definitions section for a listing of counties

To locate a provider in Empirersquos operating area visit wwwempirebluecom You can search for providers by name address language spoken specialty and hospital affiliation The search results include a map and directions to the providerrsquos office Or ask your Benefits Administrator to see Empirersquos PPO Directory

You can also request that a directory be mailed to you free of charge by calling Member Services at 1-855-519-9537 Call 1-800-810-BLUE (2583) or visit wwwbcbscom to locate participating BlueCard PPOreg providers

TRANSITIONAL CARE Networks grow and change and sometimes a provider will move or leave the network that serves your Plan If you are an existing member and the provider with whom you are in an ongoing course of treatment leaves the network Empire will notify you at least 30 calendar days prior to the physicianrsquos termination or within 15 days after we become aware of the providerrsquos change in status You may continue to receive medically necessary covered services from a provider for an ongoing course of treatment for up to 90 days after heshe leaves the network if the provider agrees to (1) reimbursement at the rates applicable prior to start of transitional care (2) to adhere to the planrsquos quality assurance requirements (3) to provide the plan with necessary medical information related to this care and (4) to adhere to the plans policies and procedures After 90 days you must select a new provider Continued care is available to pregnant women who are in the second and third trimester through the delivery and postpartum period You must contact our Medical Management department to arrange this continued care Transitional care will not be approved if the provider leaves the network due to imminent harm to patient care a determination of fraud or a final disciplinary action by a state licensing board (or other governmental agency) that impairs the health care professionalrsquos ability to practice New plan members who are in treatment for a disabling and degenerative or life threatening condition or disease are eligible for up to 60 days of continued care following their initial enrollment date Members who are pregnant and in their second or third trimester on the effective date of coverage may continue care through delivery and the postpartum period The provider must agree to (1) reimbursement at the rates applicable prior to start of transitional care (2) to adhere to the planrsquos quality assurance requirements (3) to provide the plan with necessary medical information related to this care and (4) to adhere to the plans policies and procedures in both situations You must contact our Medical Management department to arrange this continued care

INTER-PLAN PROGRAMS Out-of-Area Services

Empire has a variety of relationships with other Blue Cross andor Blue Shield Licensees referred to generally as ldquoInter-Plan Programsrdquo Whenever you obtain healthcare services outside of Empirersquos service area the claims for these services may be processed through one of these Inter-Plan Programs which include the BlueCard Program and may include negotiated National Account arrangements available between Empire and other Blue Cross and Blue Shield Licensees

Typically when accessing care outside Empirersquos service area you will obtain care from healthcare providers that have a contractual agreement (ie are ldquoparticipating providersrdquo) with the local Blue Cross andor Blue Shield Licensee in that other geographic area (ldquoHost Bluerdquo) In some instances you may obtain care from nonparticipating healthcare providers Empirersquos payment practices in both instances are described below

BlueCardreg Program Under the BlueCardreg Program when you access covered healthcare services within the geographic area served by a Host Blue Empire will remain responsible for fulfilling Empirersquos contractual obligations However the Host Blue is responsible for contracting with and generally handling all interactions with its participating healthcare providers

Whenever you access covered healthcare services outside Empirersquos service area and the claim is processed through the BlueCard Program the amount you pay for covered healthcare services is calculated based on the lower of

x The billed covered charges for your covered services or x The negotiated price that the Host Blue makes available to Empire

Often this ldquonegotiated pricerdquo will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider Sometimes it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements incentive payments andor other credits or charges Occasionally it may

wwwempirebluecom 9

be an average price based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price

Estimated pricing and average pricing going forward also take into account adjustments to correct for over- or underestimation of modifications of past pricing for the types of transaction modifications noted above However such adjustments will not affect the price Empire uses for your claim because they will not be applied retroactively to claims already paid

Laws in a small number of states may require the Host Blue to add a surcharge to your calculation If any state laws mandate other liability calculation methods including a surcharge we would then calculate your liability for any covered healthcare services according to applicable law

Under certain circumstances if Empire pays the healthcare provider amounts that are your responsibility such as Deductibles Copayments or Coinsurance Empire may collect such amounts directly from you You agree that Empire has the right to collect such amounts from you

Non-Participating Healthcare Providers Outside Empirersquos Service Area Your Liability Calculation

When covered healthcare services are provided outside of Empirersquos service area by non-participating healthcare providers the amount you pay for such services will generally be based on either the Host Bluersquos nonparticipating healthcare provider local payment or the pricing arrangements required by applicable state law In these situations you may be liable for the difference between the amount that the non-participating healthcare provider bills and the payment Empire will make for the Covered Services as set forth in this paragraph

Exceptions

In certain situations Empire may use other payment bases such as billed covered charges the payment we would make if the healthcare services had been obtained within our Service Area or a special negotiated payment as permitted under Inter-Plan Programs Policies to determine the amount Empire will pay for services rendered by nonparticipating healthcare providers In these situations you may be liable for the difference between the amount that the non-participating healthcare provider bills and the payment Empire will make for the covered services as set forth in this paragraph

BLUECARDreg PPO PROGRAM Care When you are Out of Our Service Area Within the US

If you are traveling outside the Empire service area the BlueCardreg PPO program lets you use other Blue Cross andor Blue Shield plansrsquo PPO networks of physicians hospitals and other health care providers As a PPO member you are automatically enrolled in the BlueCardreg PPO program This allows you to receive in-network benefits across the country outside of our network area from providers participating with other Blue Plansrsquo PPO networks As long as these services are covered services under your Contract or Certificate they will be treated as in-network services If you are traveling and need medical care call 1-800-810-BLUE (2583) for the names and addresses of the PPO providers nearest you You may also visit the Blue Cross and Blue Shield Association Web site to locate providers in other states at wwwbcbscom BlueCardpound Worldwide Program The BlueCard Worldwide program provides hospital and professional coverage through an international network of healthcare providers With this program yoursquore assured of receiving care from licensed healthcare professionals The program also assures that at least one staff member at the hospital will speak English or the program will provide translation assistance Herersquos how to use BlueCard Worldwide

x Call 1-804-673-1177 24 hours a day seven days a week for the names of participating doctors and hospitals Outside the US you may use this number by dialing an ATampT Directreg1 Access Number

x Show your Empire ID card at the hospital If yoursquore admitted you will only have to pay for expenses not covered by your contract such as co-payments coinsurance deductibles and personal items Remember to call Empire within 24 hours or as soon as reasonably possible

x If you receive outpatient hospital care or care from a doctor in the BlueCard Worldwide Program pay the bill at the time of treatment When you return home submit an international claim form and attach the bill This claim form is available from the healthcare provider or by calling the BlueCard Worldwide Program Mail the claim to the address on the form You will receive reimbursement less any coinsurance amount above the maximum allowed amount

10 wwwempirebluecom

Your Benefits at a Glance

Empirersquos plan provides a broad range of benefits to you and your family Following is a brief overview of your coverage Some services require precertification with Empirersquos Medical Management Program See the Health Management section for details

YOU PAY

HOME OFFICEOUTPATIENT CARE IN-NETWORK OUT-OF-NETWORK

HOMEOFFICE VISITS $15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

ONLINE VISITS $15 Primary co-payment per visit

Deductible and 20 coinsurance

SPECIALIST VISITS $20 co-payment per visit Deductible and 20 coinsurance

CHIROPRACTIC CARE x Up to an annual in-network and out of network maximum of $1000

$15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

SECOND OR THIRD SURGICAL OPINION $10 co-payment per visit Deductible and 20 coinsurance

DIABETES EDUCATION AND MANAGEMENT $10 co-payment per visit Deductible and 20 coinsurance

ALLERGY CARE x Office Visit x Testing x Treatment

$15 per visit (Non-Specialist) $20 per visit (Specialist) $0 $0

Deductible and 20 coinsurance

SURGERY $0 Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

Empirersquos Medical Management Program must be contacted to determine medical necessity of all in-network and out-of-network chiropractic care after

the fifth visit We will not pay for any visits which we determine were not medically necessary in accordance with your contract

wwwempirebluecom 11

YOU PAY

HOME OFFICEOUTPATIENT CARE IN-NETWORK OUT-OF-NETWORK

DIAGNOSTIC PROCEDURES

x X-rays and other imaging x Laboratory tests

$0 $0

Deductible and 20 coinsurance

CHEMOTHERAPY $0 Deductible and 20 coinsurance

HIGH COST DIAGNOSTIC TESTS (ie MRIsMRAs Nuclear cardiology servicesPETCAT scans)

$0 Deductible and 30 coinsurance

RADIATION $0 Deductible and 20 coinsurance

PRE-SURGICAL TESTING $0 Deductible and 20 coinsurance

ANESTHESIA $0 Deductible and 20 coinsurance

KIDNEY DIALYSIS $0 Deductible and 20 coinsurance

SECOND OR THIRD MEDICAL OPINION FOR CANCER DIAGNOSIS

$15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

CARDIAC REHABILITATION $15 per visit (Non-Specialist)

$20 per visit (Specialist) Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

12 wwwempirebluecom

YOU PAY

HOME OFFICEOUTPATIENT CARE IN-NETWORK OUT-OF-NETWORK

ANNUAL PHYSICAL EXAM x One per calendar year

$15 per visit (Non-Specialist)

$20 per visit (Specialist) Not covered

DIAGNOSTIC SCREENING TESTS x Cholesterol 1 every 2 years (except for triglyceride testing) x Diabetes (if pregnant or considering pregnancy) x Colorectal cancer

ndash Fecal occult blood test if age 40 or over 1 per year ndash Sigmoidoscopy if age 40 or over 1 every 2 years

x Routine Prostate Specific Antigen (PSA) in asymptomatic males ndash Over age 50- 1 every year ndash Between ages 40-49 if risk factors exist 1 per year ndash If prior history of prostate cancer PSA at any age ndash Diagnostic PSA 1 per year

$0 $0

$0

$0

Deductible and 20 coinsurance

WELL-WOMAN CARE x Office visits x Pap smears x Bone Density testing and treatment

ndash Ages 55 through 65 - 1 baseline ndash Age 65 and older - 1 every 2 years (if baseline before

age 65 does not indicate osteoporosis) ndash under Age 65 - 1 every 2 years (if baseline before age

65 indicates osteoporosis) x Mammogram (based on age and medical history)

ndash Ages 35 through 39 ndash 1 baseline ndash Age 40 and older ndash 1 per year

x Womenrsquos sterilization procedures and counseling x Breastfeeding support supplies and counseling

ndash One breast pump per pregnancy x Screenings andor counseling for Gestational diabetes

Human Papillomavirus (HPV) sexually transmitted infections STIs) Human immune deficiency (HIV) interpersonal and domestic violence

$15 per visit (Non-Specialist) $20 per visit (Specialist)

$0 $0

$0

$0 $0

$0

Deductible and 20 coinsurance

WELL-CHILD CARE (covered services and the number of visits are based on the prevailing clinical standards of the American Academy of Pediatrics) x In-hospital visits

ndash Newborn 2 in-hospital exams at birth following vaginal delivery

ndash Newborn 4 in-hospital exams at birth following c-section delivery

x Office visits ndash From birth up 1st birthday 7 visits ndash Ages 1 through 4 years of age 6 visits ndash Ages 5 through 11 years of age 7 visits ndash Ages 12 up to 17 years of age 6 visits ndash Ages 18 to 19th birthday 2 visits

x Lab tests x Immunizations (office visits are not required)

$0

$0

$0 $0

$0

$0

Deductible and 20 coinsurance Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements See the Preventive Care section for more details

wwwempirebluecom 13

YOU PAY

EMERGENCY CARE IN-NETWORK OUT-OF-NETWORK

EMERGENCY ROOM $75 per visit co-payment (waived if admitted to the same hospital within 24 hours)

PHYSICIANrsquoS OFFICE $15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

EMERGENCY AIR AMBULANCE x Transportation to nearest acute care hospital for

emergency inpatient admissions

$0

Covered in-network when specified criteria is met subject to any applicable cost sharing You may be required to pay the difference between the maximum allowed amount and the total charges of an out-of-network provider

EMERGENCY LAND AMBULANCE x Local professional ground ambulance to

nearest hospital $0 up to the maximum allowed

amount

Covered in-network subject to meeting emergency criteria When services are delivered by an out-of-network land ambulance provider that is not licensed under the NY Public Health Law you may be required to pay up to the difference between the maximum allowed amount and the providerrsquos total charges13

MATERNITY CARE IN-NETWORK OUT-OF-NETWORK

PRENATAL AND POSTNATAL CARE (In doctorrsquos office) $0 Deductible and 20 coinsurance

LAB TESTS SONOGRAMS AND OTHER DIAGNOSTIC PROCEDURES $0 Deductible and 20 coinsurance

ROUTINE NEWBORN NURSERY CARE (In hospital) $0 Deductible and 20 coinsurance

OBSTETRICAL CARE (In hospital) $0 Deductible and 20 coinsurance

OBSTETRICAL CARE (In birthing center) $0 Not covered

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

13 New York State law prohibits land ambulance providers in New York State from balance-billing beyond reasonable and customary amounts (you will be responsible for in-network cost share such as co-payments deductibles and coinsurance)

14 wwwempirebluecom

YOU PAY

HOSPITAL SERVICES IN-NETWORK OUT-OF-NETWORK

SEMI-PRIVATE ROOM AND BOARD $0 Deductible and 20 coinsurance

ANESTHESIA AND OXYGEN $0 Deductible and 20 coinsurance

CHEMOTHERAPY AND RADIATION THERAPY $0 Deductible and 20 coinsurance

DIAGNOSTIC X-RAYS AND LAB TESTS $0 Deductible and 20 coinsurance

DRUGS AND DRESSINGS $0 Deductible and 20 coinsurance

GENERAL SPECIAL AND CRITICAL NURSING CARE $0 Deductible and 20 coinsurance

INTENSIVE CARE $0 Deductible and 20 coinsurance

KIDNEY DIALYSIS $0 Deductible and 20 coinsurance

SERVICES OF LICENSED PHYSICIANS AND SURGEONS $0 Deductible and 20 coinsurance

SURGERY (Inpatient and Outpatient) $0 Deductible and 20 coinsurance

DURABLE MEDICAL EQUIPMENT AND SUPPLIES IN-NETWORK OUT-OF-NETWORK

DURABLE MEDICAL EQUIPMENT (ie hospital-type bed wheelchair sleep apnea monitor)

$0 Not covered

ORTHOTICS $0 Not covered

PROSTHETICS (ie artificial arms legs eyes ears) $0 Not covered

MEDICAL SUPPLIES (ie catheters oxygen syringes) $0

Difference between the maximum allowed amount and the total charge ( coinsurance does not apply)

NUTRITIONAL SUPPLEMENTS (enteral formulas and modified solid food products)

$0 Deductible and 20 coinsurance

HEARING AIDS (one device per ear every 3 years maximum of $1500 combined in and out-of-network) $0 Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

Does not include inpatient or outpatient behavioral healthcare or physical therapyrehabilitation For a second procedure performed during an authorized surgery through the same incision Empire pays for the procedure with the higher maximum allowed amount For a second procedure done through a separate incision Empire will pay the maximum allowed amount for the procedure with the higher allowance and up to 50 of the maximum allowed amount for the other procedure $0 outside of the United States

wwwempirebluecom 15

YOU PAY

SKILLED NURSING AND HOSPICE CARE IN-NETWORK OUT-OF-NETWORK

SKILLED NURSING FACILITY Up to 120 days per calendar year $0 Not covered

HOSPICE Unlimited days per lifetime $0 Not covered

HOME HEALTH CARE IN-NETWORK OUT-OF-NETWORK

HOME HEALTH CARE

Up to 200 visits per calendar year (a visit equals 4 hours of care)

$0

Deductible and 20 coinsurance only

HOME INFUSION THERAPY $0 Not covered

PHYSICAL OCCUPATIONAL SPEECH OR VISION THERAPY IN-NETWORK OUT-OF-NETWORK

PHYSICAL THERAPY AND REHABILITATION

x Up to 60 days of inpatient service per calendar year

x Up to 60 visits combined in home office or outpatient facility per calendar year

$20 per visit (Specialist)

$15 per visit (Non-Specialist)

$20 per visit (Specialist)

Deductible and 20 coinsurance

Deductible and 20 coinsurance

OCCUPATIONAL AND SPEECH THERAPY

x Up to 60 visits per person combined in home office or outpatient facility per calendar year

$15 per visit (Non-Specialist) $20 per visit (Specialist) Deductible and 20 coinsurance

VISION THERAPY

x Up to 60 visits per person combined in home or office per calendar year

$15 per visit (Non-Specialist) $20 per visit (Specialist) Deductible and 20 coinsurance

Please refer to the Health Management section and your certificate or contract for details regarding precertification requirements

Treatment maximums are combined for in-network and out-of-network care $0 outside of the United States

16 wwwempirebluecom

YOU PAY

MENTAL HEALTH CARE IN-NETWORK OUT-OF-NETWORK

OUTPATIENT x Up to 60 visits per calendar year 1

$25 co-payment Deductible and 20 coinsurance

INPATIENT x Up to 90 days per calendar year 1

x Up to 90 visits from mental health care professionals

per calendar year 1

$0

$0

Deductible and 20 coinsurance

Deductible and 20 coinsurance

ALCOHOL OR SUBSTANCE ABUSE TREATMENT IN-NETWORK OUT-OF-NETWORK

OUTPATIENT x Up to 60 visits per calendar year including up to

20 visits for family counseling $0 Deductible and 20 coinsurance

INPATIENT x Up to 7 days detoxification per calendar year 1 x Up to 30 days rehabilitation per calendar year 1

$0 $0

Deductible and 20 coinsurance

Deductible and 20 coinsurance

PHARMACY (RETAIL AND MAIL SERVICE) IN-NETWORK OUT-OF-NETWORK

RETAIL PHARMACY (34 day supply) x Tier 1 x Tier 2

x Tier 3

x 20 co-payment $5 minimum and up to a maximum of $20 per prescription

x 25 co-payment $5 minimum and up to a maximum of $30 per prescription

x 25 co-payment $5 minimum and up to a maximum of $30 per prescription

x

40 Coinsurance

(within the United States)

20 Coinsurance

(outside the United States)

x

MAIL SERVICE (90 day supply-includes some specific Retail locations)

x $15 co-payment Not covered

Generic and Select Oral Contraceptives and Contraceptive Devices

x $0 cost share Not covered

(All of the prescription drug options listed above meet the Centers for Medicare and Medicaid Services (CMS) standards for Medicare prescription drug coverage and each option is considered Creditable Coverage under the Medicare Modernization Act of 2003)

OTHER SERVICES IN-NETWORK OUT-OF-NETWORK SEX CHANGE SURGERY OR TREATMENT OF GENDER IDENTITY DISORDERS (for hospital inpatient only) x Lifetime Maximum $75000 for transformative surgeries

Lifetime Maximum combined In-network and Out-of-Network

$0 Deductible and 20 coinsurance

Treatment maximums are combined for in-network and out-of-network care

wwwempirebluecom 17

Coverage

Doctorrsquos Services When you need to visit your doctor or a specialist Empire makes it easy In-network you pay only a co-payment There are no claim forms to fill out for X-rays blood tests or other diagnostic procedures ndash as long as they are requested by the doctor and done in the doctorrsquos office or a network facility For in-network allergy office visits you pay only a co-payment In-network allergy testing is covered in full Ongoing in-network allergy treatments are covered in full

When you visit an out-of-network physician or use an out-of-network facility for diagnostic procedures including allergy testing and treatment visits you pay the deductible and coinsurance plus any amount above Empirersquos allowed amount

Tips For Visiting Your Doctor x When you make your appointment confirm that the doctor is an Empire network provider and that heshe is

accepting new patients

x Arrange ahead of time to have pertinent medical records and test results sent to the doctor

x If the doctor sends you to an outside lab or radiologist for tests or X-rays call Member Services to confirm that the supplier is in Empirersquos network This will ensure that you receive maximum benefits

Ask about a second opinion anytime that you are unsure about surgery or a cancer diagnosis The specialist who provides the second or third opinion cannot perform the surgery To confirm a cancer diagnosis or course of treatment second or third opinions are paid at the in-network level even if you use an out-of-network specialist as long as your participating doctor provides a written referral to a non-participating specialist If you visit a non-participating specialist without a written referral you must pay the out-of-network deductible and coinsurance

WOMENrsquoS HEALTH AND CANCER RIGHTS OF ACT 1998

This federal law applies to almost all health care plans except Medicare Supplement and Medicare Risk plans as of plan years beginning on or after October 21 1998 The law imposes certain requirements on employee benefit plans and health insurers that provide medical and surgical benefits with respect to a mastectomy Specifically in the case of a participant or beneficiary who receives benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy the law requires coverage for

x Reconstruction of the breast on which the mastectomy has been performed x Surgery and reconstruction of the other breast to produce a symmetrical appearance x Prostheses and treatment of physical complications at all stages of mastectomy including lymphedemas

The coverage described above shall be provided in a manner determined in consultation with the attending physician and the patient This coverage is subject to all coverage terms and limitations (for example Deductibles and Coinsurance) consistent with those established for other benefits under the plan

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Consultation requested by the attending physician for advice on an illness or injury

This includes the Specialist e-Consultations Program If Your Participating Provider is in Our Cooperative Care program and is rendering primary care services to You he or she may request an electronic consultation with a Specialist to help evaluate Your condition or diagnosis The electronic consultation will be provided by a Participating Provider who has agreed to participate in Our ldquoeconsultationrdquo program and will be selected by Your Participating Provider in his or her clinical judgement The electronic consultation will be at no cost to You Your Participating Provider may consider the information provided by the Specialist in determining Your treatment The consultation will be conducted using electronic information and communication technologies such as secure web-based email fax andor exchange of electronic medical records The results may be documented in an electronic health record

x Diabetes supplies prescribed by an authorized provider Blood glucose monitors including monitors for the legally blind

18 wwwempirebluecom

Testing strips Insulin syringes injection aids cartridges for the legally blind insulin pumps and appurtenances and insulin

infusion devices Oral agents for controlling blood sugar Other equipment and supplies required by the New York State Health Department Data management systems

x Diabetes self-management education and diet information including

Education by a physician certified nurse practitioner or member of their staff frac34 At the time of diagnosis frac34 When the patientrsquos condition changes significantly frac34 When medically necessary

Education by a certified diabetes nurse educator certified nutritionist certified dietitian or registered dietitian when referred by a physician or certified nurse practitioner This benefit may be limited to a group setting when appropriate

Home visits for education when medically necessary

x Diagnosis and treatment of degenerative joint disease related to temporomandibular joint (TMJ) syndrome that is not a dental condition

x Diagnosis and treatment for Orthognathic surgery that is not a dental condition

x Medically necessary hearing examinations

x Foot care and orthotics associated with disease affecting the lower limbs such as severe diabetes which requires care from a podiatrist or physician

x Gender Reassignment Surgery and related non-cosmetic services

Lifetime Maximum benefit of $75000 for transgender surgery Counseling Services are covered These services will not count toward the $75000 Lifetime Maximum Benefit

x Cosmetic Services received in association with gender transformation are NOT covered including

x Reduction Thyroid Chondroplasty x Liposuction x Rhinoplasty x Facial Bone Reconstruction x Face Lift x Blepharoplasty x Voice Modification Surgery x Hair Removalhairplasty x Breast Augmentation

ONLINE VISITS

Your coverage includes online physician office visits Covered Services include a medical consultation using the internet via a webcam with online chat or voice functions Services are provided by board certified licensed primary care physicians Online visits are not for specialist care Common types of diagnoses and conditions treated online are cough fever headaches sore throat routine child health issues influenza upper respiratory infections sinusitis bronchitis and urinary tract infections when uncomplicated in nature Online visits are not meant for the following purposes

To get reports of normal lab or other test results To request an office appointment To ask billing insurance coverage or payment questions To ask for a referral to a specialist Doctor To request precertification for a benefit under your health Plan or To ask the physician to consult with another physician

You must have the following computer hardware in order for the online website to work properly USB or built in webcam (to enable two-way video during web conversations) and audio functionality To minimize audio feedback use a headset or headphones with a built-in microphone To begin the online visit log on to wwwlivehealthonlinecom and establish an

wwwempirebluecom 19

online account by providing some basic information about you and your insurance plan Before you connect to a Doctor you will be asked the kind of condition you want to discuss with the Doctor list your local pharmacy provide information for the credit card you want your cost share for the visit to be billed to agree to the terms of use and select an available physician If you are not in New York State when you seek an online visit you will need to check to be sure an online Doctor is available in the state you are in because online Doctors are not available in every state The visit with the physician will not start until you provide the above information and click ldquoconnectrdquo The visit will be documented in an electronic health record You may access your records and print them and may email or fax them to your primary care physician

CLINICAL TRIALS We Cover the routine patient costs for Your participation in an approved clinical trial and such coverage shall not be subject to Utilization Review if You are

x Eligible to participate in an approved clinical trial to treat either cancer or other life-threatening disease or condition and

x Referred by a Participating Provider who has concluded that Your participation in the approved clinical trial would be appropriate

All other clinical trials including when You do not have cancer or other life-threatening disease or condition may be subject to the Utilization Review and External Appeal sections of this booklet We do not Cover the costs of the investigational drugs or devices the costs of non-health services required for You to receive the treatment the costs of managing the research or costs that would not be covered under this benefit plan for non-investigational treatments provided in the clinical trial An ldquoapproved clinical trialrdquo means a phase I II III or IV clinical trial that is

x A federally funded or approved trial x Conducted under an investigational drug application reviewed by the federal Food and Drug Administration or x A drug trial that is exempt from having to make an investigational new drug application

Whatrsquos Not Covered The following medical services are not covered

x Routine foot care including care of corns bunions calluses toenails flat feet fallen arches weak feet and chronic foot strain

x Symptomatic complaints of the feet except capsular or bone surgery related to bunions and hammertoes x Orthotics for treatment of routine foot care x Routine hearing exams x Services such as laboratory X-ray and imaging and pharmacy services as required by law from a facility in which

the referring physician or hisher immediate family member has a financial interest or relationship x Services given by an unlicensed provider or performed outside the scope of the providerrsquos license

20 wwwempirebluecom

Emergency Care IF YOU NEED EMERGENCY CARE

Should you need emergency care your plan is there to cover you Emergency care is covered in the hospital emergency room

To be covered as emergency care the condition must be a medical or behavioral condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in

1 Placing the health of the person afflicted with such condition (or with respect to a pregnant woman the health of the woman or her unborn child) in serious jeopardy or in the case of a behavioral condition placing the health of such person or others in serious jeopardy

2 Serious impairment to such personrsquos bodily functions 3 Serious dysfunction of any bodily organ or part of such person or

4 Serious disfigurement of such person

Emergency Services are defined as a medical screening examination that is within the capability of the emergency department of a Hospital including ancillary services routinely available to the emergency department to evaluate an Emergency Condition and within the capabilities of the staff and facilities available at the Hospital such further medical examination and treatment as are required to stabilize the patient With respect to an emergency medical condition the term ldquoStabilizerdquo means to provide such medical treatment of the condition as may be necessary to assure within reasonable medical probability that no material deterioration of the condition is likely to result from or occur during the transfer of the patient from a facility or to deliver a newborn child (including the placenta)

Emergency Services are not subject to prior authorization requirements

Emergency Assistance 911 In an emergency call 911 for an ambulance or go directly to the nearest emergency room If possible go to the emergency room of a hospital in Empirersquos PPO network or the PPO network of another Blue Cross andor Blue Shield plan

You pay only a co-payment for a visit to an emergency room This co-payment is waived if you are admitted to the hospital within 24 hours If you make an emergency visit to your doctorrsquos office you pay the same co-payment as for an office visit

Benefits for treatment in a hospital emergency room are limited to the initial visit for an emergency condition A participating provider must provide all follow-up care in order to receive maximum benefits Remember You will need to show your Empire BlueCross BlueShield ID card when you arrive at the emergency room

Tips For Getting Emergency Care x If time permits speak to your physician to direct you to the best place for treatment x If you have an emergency while outside Empirersquos service area anywhere in the United States follow the same steps

described on the previous page If the hospital participates with another Blue Cross andor Blue Shield plan in the BlueCardpound PPO program your claim will be processed by the local plan Be sure to show your Empire ID card at the emergency room If the hospital does not participate in the BlueCard PPO program you will need to file a claim

x If you have an emergency outside of the United States and visit a hospital which participates in the BlueCardpound

Worldwide program simply show your Empire ID card The hospital will submit their bill through the BlueCard Worldwide Program If the hospital does not participate with the BlueCard Worldwide program you will need to file a claim

Please refer to the Health Management section for details regarding precertification requirements

wwwempirebluecom 21

Whatrsquos Not Covered These emergency services are not covered

x Use of the Emergency Room To treat routine ailments Because you have no regular physician Because it is late at night (and the need for treatment is not sudden and serious)

Emergency Air Ambulance We will provide in-network coverage for air ambulance services when needed to transport you to the nearest acute care hospital in connection with an emergency room or emergency inpatient admission or emergency outpatient care subject to cost sharing obligations when the following conditions are met

x Your medical condition requires immediate and rapid ambulance transportation and services cannot be provided by land ambulance due to great distances and the use of land transportation would pose an immediate threat to your health

x Services are covered to transport you from one acute care hospital to another only if the transferring hospital does not have adequate facilities to provide the medically necessary services needed for your treatment as determined by Empire and use of land ambulance would pose an immediate threat to your health

If Empire determines that the condition for coverage for air ambulance services has not been met but your condition did require transportation by land ambulance to the nearest acute care hospital Empire will only pay up to the maximum allowed amount that would be paid for land ambulance to that hospital You may be required to pay the difference between the maximum allowed amount and the total charges of an out-of-network provider

Please refer to the Health Management section for details regarding precertification requirements

Emergency Land Ambulance We will provide coverage for land ambulance transportation to the nearest acute care hospital in connection with emergency room care or emergency inpatient admission provided by an ambulance service when a prudent layperson possessing an average knowledge of medicine and health could reasonably expect the absence of such transportation to result in

x placing the memberrsquos health afflicted with a condition in serious jeopardy or for behavioral condition place the health of a member or others in serious jeopardy or

x serious impairment to a personrsquos bodily functions x serious dysfunction of any bodily organ or part of a person or x serious disfigurement to the member

Non-Emergency Ambulance Transportation

We cover non-emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance as appropriate) between facilities when the transport is any of the following

x From a non-participating Hospital to a participating Hospital x To a Hospital that provides a higher level of care that was not available at the original Hospital x To a more cost-effective Acute care Facility or x From an Acute Facility to a sub-Acute setting LimitationsTerms of Coverage

x We do not cover travel or transportation expenses unless connected to an Emergency Condition or due to a Facility transfer approved by us even though prescribed by a Physician

x We do not cover non-ambulance transportation such as ambulette van or taxi cab x Coverage for air ambulance related to an Emergency Condition or air ambulance related to non-emergency

transportation is provided when your medical condition is such that transportation by land ambulance is not appropriate and your medical condition requires immediate and rapid ambulance transportation that cannot be provided by land ambulance and one of the following is met The point of pick-up is inaccessible by land vehicle or Great distances or other obstacles (for example heavy traffic) prevent your timely transfer to the nearest Hospital

with appropriate facilities

22 wwwempirebluecom

Maternity Care IF YOU ARE HAVING A BABY

There are no out-of-pocket expenses for maternity and newborn care when you use in-network providers That means you do not need to pay a co-payment when you visit the obstetrician Furthermore routine tests related to pregnancy obstetrical care in the hospital or birthing center as well as routine newborn nursery care are all covered 100 in-network

For out-of-network maternity services you pay the deductible coinsurance and any amount above the maximum allowed amount Empirersquos reimbursements for the remaining balance may be consolidated in up to three installments as follows

x Two payments for prenatal care x One payment for delivery and post-natal care

Please refer to the Health Management section for details regarding precertification requirements Obstetrical care in the hospital or an in-network birthing center is covered up to 48 hours after a normal vaginal birth and 96 hours after a Cesarean section

NEWBORNSrsquo AND MOTHERSrsquo HEALTH PROTECTION ACT OF 1996 Group health plans and health insurance issuers generally may not under Federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section However Federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under Federal law require that a provider obtain authorization from the Program or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours as applicable) Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x One home care visit if the mother leaves earlier than the 48-hour (or 96-hour) limit The mother must request the visit from the hospital or a home health care agency within this timeframe (precertification is not required) The visit will take place within 24 hours after either the discharge or the time of the request whichever is later

x Services of a certified nurse-midwife affiliated with a licensed facility The nurse-midwifersquos services must be provided under the direction of a physician

x Parent education and assistance and training in breast or bottle feeding if available x Circumcision of newborn males x Special care for the baby if the baby stays in the hospital longer than the mother Call Empirersquos Medical Management

Program to precertify the hospital stay x Semi-private room

Whatrsquos Not Covered These maternity care services are not covered

x Days in hospital that are not medically necessary (beyond the 48-hour96-hour limits) x Services that are not medically necessary x Private room x Out-of-network birthing center facilities x Private duty nursing

REMEMBER Use a network obstetriciangynecologist to receive the lowest cost maternity care

wwwempirebluecom 23

Hospital Services IF YOU VISIT THE HOSPITAL

Your plan covers most of the cost of your medically necessary care when you stay at a network hospital for surgery or treatment of illness or injury When you use an out-of-network hospital or facility you pay the deductible and coinsurance plus any amount above Empirersquos maximum allowed amount

You are also covered for same-day (outpatient or ambulatory) hospital services such as chemotherapy radiation therapy cardiac rehabilitation and kidney dialysis Same-day surgical services or invasive diagnostic procedures are covered when they

x Are performed in a same-day or hospital outpatient surgical facility x Require the use of both surgical operating and postoperative recovery rooms x May require either local or general anesthesia x Do not require inpatient hospital admission because it is not appropriate or medically necessary and x Would justify an inpatient hospital admission in the absence of a same-day surgery program

Please refer to the Health Management section for details regarding precertification requirements

Tip For Getting Hospital Care x If you are having same-day surgery often the hospital or outpatient facility requires that someone meet you after the

surgery to take you home Ask about their policy and make arrangements for transportation before you go in for surgery

Inpatient And Outpatient Hospital Care

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations for both inpatient and outpatient (same-day) care

x Diagnostic X-rays and lab tests and other diagnostic tests such as EKGs EEGs or endoscopies x Oxygen and other inhalation therapeutic services and supplies and anesthesia (including equipment for administration x Anesthesiologist including one consultation before surgery and services during and after surgery x Blood and blood derivatives for emergency care same-day surgery or medically necessary conditions such as

treatment for hemophilia x MRIsMRAs PETCAT scans and nuclear cardiology services

Please refer to the Health Management section for details regarding precertification requirements

Inpatient Hospital Care

Whatrsquos Covered Following are additional covered services for inpatient care

x Semi-private room and board when The patient is under the care of a physician and A hospital stay is medically necessary

x Coverage is for unlimited days unless otherwise specified x Operating and recovery rooms x Special diet and nutritional services while in the hospital x Cardiac care unit x Services of a licensed physician or surgeon employed by the hospital x Care related to surgery x Breast cancer surgery (lumpectomy mastectomy) including

Reconstruction following surgery Surgery on the other breast to produce a

symmetrical appearance

Prostheses Treatment of physical complications at any stage of a

mastectomy including lymphedemas The patient has the right to decide in consultation with the physician the length of hospital stay following mastectomy surgery

x Use of cardiographic equipment x Drugs dressings and other medically necessary supplies x Social psychological and pastoral services x Reconstructive surgery associated with injuries unrelated to cosmetic surgery x Reconstructive surgery for a functional defect which is present from birth x Physical occupational speech and vision therapy including facilities services supplies and equipment x Facilities services supplies and equipment related to medically necessary medical care x Residential treatment services are not covered

Please refer to the Health Management section for details regarding precertification requirements

24 wwwempirebluecom

Outpatient Hospital Care

Whatrsquos Covered Following are additional covered services for same-day care

x Same-day and hospital outpatient surgical facilities x Surgeons x Surgical assistant if

None is available in the hospital or facility where the surgery is performed and The surgical assistant is not a hospital employee

x Chemotherapy and radiation therapy including medications in a hospital outpatient department doctorrsquos office or facility Medications that are part of outpatient hospital treatment are covered if they are prescribed by the hospital and filled by the hospital pharmacy

x Kidney dialysis treatment (including hemodialysis and peritoneal dialysis) is covered in the following settings until the patient becomes eligible for end-stage renal disease dialysis benefits under Medicare At home when provided supervised and arranged by a physician and the patient has registered with an approved

kidney disease treatment center (professional assistance to perform dialysis and any furniture electrical plumbing or other fixtures needed in the home to permit home dialysis treatment are not covered

In a hospital-based or free-standing facility See ldquohospitalfacilityrdquo in the Definitions section

Please refer to the Health Management section for details regarding precertification requirements

Inpatient Hospital Care

Whatrsquos Not Covered These inpatient services are not covered

x Private duty nursing x Private room If you use a private room you need to pay the difference between the cost for the private room and the

hospitalrsquos average charge for a semiprivate room The additional cost cannot be applied to your deductible or coinsurance

x Diagnostic inpatient stays unless connected with specific symptoms that if not treated on an inpatient basis could result in serious bodily harm or risk to life

x Services performed in the following Nursing or convalescent homes Institutions primarily for rest or for the aged Rehabilitation facilities (except for physical therapy)

Spas Sanitariums Infirmaries at schools colleges or camps

x Any part of a hospital stay that is primarily custodial x Elective cosmetic surgery or any related complications x Hospital services received in clinic settings that do not meet Empirersquos definition of a hospital or other covered facility

See ldquohospitalfacilityrdquo in the Details and Definitions section

Outpatient Hospital Care

Whatrsquos Not Covered These outpatient services are not covered

x Same-day surgery not precertified as medically necessary by Empirersquos Medical Management Program x Routine medical care including but not limited to

Inoculation or vaccination Drug administration or injection excluding chemotherapy

x Collection or storage of your own blood blood products semen or bone marrow

wwwempirebluecom 25

Durable Medical Equipment and Supplies IF YOU NEED EQUIPMENT OR MEDICAL SUPPLIES

Your plan covers the cost of medically necessary prosthetics orthotics and durable medical equipment from network suppliers only In-network benefits and plan maximums are shown in Your Benefits at a Glance section Out-of-network benefits are not available

Please refer to the Health Management section for details regarding precertification requirements

An Empire network supplier may not bill you for covered services If you receive a bill from one of these providers contact Member Services at 1-855-519-9537

Disposable medical supplies such as syringes are covered up to the maximum allowed amount whether you obtain them in- or out-of-network

Coverage for enteral formulas or other dietary supplements for certain severe conditions is available both in- and out-of network If you have prescription drug coverage with Empirersquos pharmacy program you may order these formulas or supplements through Empirersquos pharmacy program Whatrsquos Covered Covered services are listed in Your Benefits At A Glance section Following are additional covered services and limitations

x Prosthetics orthotics and durable medical equipment from network suppliers when prescribed by a doctor including Artificial arms legs eyes ears nose larynx and external breast prostheses Prescription lenses if organic lens is lacking Supportive devices essential to the use of an artificial limb Corrective braces Wheelchairs hospital-type beds oxygen equipment sleep apnea monitors

x Rental (or purchase when more economical) of medically necessary durable medical equipment x Replacement of covered medical equipment because of wear damage or change in patientrsquos need when ordered by a

physician x Reasonable cost of repairs and maintenance for covered medical equipment x Enteral formulas with a written order from a physician or other licensed health care provider The order must

state that The formula is medically necessary and effective and Without the formula the patient would become malnourished suffer from serious physical disorders or die

x Modified solid food products for the treatment of certain inherited diseases A physician or other licensed healthcare provider must provide a written order

x Hearing aids and the examination for their fitting Please refer to the Health Management section for details regarding precertification requirements

Whatrsquos Not Covered The following equipment is not covered x Air conditioners or purifiers x Humidifiers or dehumidifiers x Exercise equipment

x Swimming pools x False teeth

26 wwwempirebluecom

Skilled Nursing and Hospice Care IF YOU NEED SKILLED NURSING OR HOSPICE CARE

You receive coverage through Empirersquos PPO for inpatient care in a skilled nursing facility or hospice Benefits are available for network facilities only Benefits and plan maximums are shown in Your Benefits at a Glance section

Please refer to the Health Management section for details regarding precertification requirements

Skilled Nursing Care

Whatrsquos Covered You are covered for inpatient care in a network skilled nursing facility if you need medical care nursing care or rehabilitation services The number of covered days is listed in Your Benefits at a Glance section Prior hospitalization is not required in order to be eligible for benefits Services are covered if

x The doctor provides A referral and written treatment plan A projected length of stay

An explanation of the services the patient needs and The intended benefits of care

x Care is under the direct supervision of a physician registered nurse (RN) physical therapist or other healthcare professional

Whatrsquos Not Covered The following skilled nursing care services are not covered

x Skilled nursing facility care that primarily Gives assistance with daily living activities Is for rest or for the aged Treats drug addiction or alcoholism

Convalescent care Sanitarium-type care Rest cures

Hospice Care Empire covers unlimited days of hospice care once in a covered personrsquos lifetime Hospices provide medical and supportive care to patients who have been certified by their physician as having a life expectancy of twelve (12) months or less Hospice care can be provided in a hospice in the hospice area of a network hospital or at home as long as it is provided by a network hospice agency

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Hospice care services including Up to 12 hours of intermittent care each day by a registered nurse (RN) or licensed practical nurse (LPN) Medical care given by the hospice doctor Drugs and medications prescribed by the patientrsquos doctor that are not experimental and are approved for use by

the most recent Physiciansrsquo Desk Reference Physical occupational speech and respiratory therapy when required for control of symptoms Laboratory tests X-rays chemotherapy and radiation therapy Social and counseling services for the patientrsquos family including bereavement counseling visits until one year

after death Transportation between home and hospital or hospice when medically necessary Medical supplies and rental of durable medical equipment Up to 14 hours of respite care in any week

Tips for Receiving Skilled Nursing and Hospice Care x To learn more about a skilled nursing facility ask your doctor or caseworker to see the Health Facilities directory x For hospice care in your home ask whether the same caregiver will come each day or whether you will see someone

new each time What recourse do you have if you are not comfortable with the caregiver

wwwempirebluecom 27

Home Health Care IF YOU NEED HOME HEALTH CARE

Home health care can be an alternative to an extended stay in a hospital or a stay in a skilled nursing facility You receive coverage when you use an in-network provider For out-of-network home health care you pay coinsurance only (the deductible does not apply) Out-of-network agencies must be certified by New York State or have comparable certification from another state Benefits and plan maximums are shown in Your Benefits at a Glance section

Home infusion therapy a service sometimes provided during home health care visits is only available in-network An Empire network home health care agency or home infusion supplier cannot bill you for covered services If you receive a bill from one of these providers contact Member Services at 1-855-519-9537 Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Up to 200 home health care visits per year combined in- and out-of-network A visit is defined as up to four hours of care Care can be given for up to 12 hours a day (three visits) Your physician must certify home health care as medically necessary and approve a written treatment plan

x Home health care services include Part-time services by a registered nurse (RN) or licensed practical nurse (LPN) Part-time home health aide services (skilled nursing care) Physical speech or occupational therapy if restorative Medications medical equipment and supplies prescribed by a doctor Laboratory tests

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Up to 200 home health care visits per year combined in- and out-of-network A visit is defined as up to four hours of care Care can be given for up to 12 hours a day (three visits) Your physician must certify home health care as medically necessary and approve a written treatment plan

x Home health care services include Part-time services by a registered nurse (RN) or licensed practical nurse (LPN) Part-time home health aide services (skilled nursing care) Physical speech or occupational therapy if restorative Medications medical equipment and supplies prescribed by a doctor Laboratory tests

Whatrsquos Not Covered The following home health care services are not covered

x Custodial services including bathing feeding changing or other services that do not require skilled care x Out-of-network home infusion therapy

28 wwwempirebluecom

Physical Occupational Speech or Vision Therapy IF YOU NEED THERAPY

You receive benefits through Empirersquos plan for physical occupational speech and vision therapy Outpatient physical occupational speech and vision therapy services are available in-network and out-of-network Inpatient physical therapy can be in-network or out-of-network

Please refer to the Health Management section for details regarding precertification requirements

Tip for Receiving Therapy x Ask for exercises you can do at home that will help you get better faster

Whatrsquos Covered Covered services are listed in Your Benefits at a Glance section Following are additional covered services and limitations

x Physical therapy physical medicine or rehabilitation services or any combination of these on an inpatient or outpatient basis up to the plan maximums if Prescribed by a physician Designed to improve or restore physical functioning within a reasonable period of time and Approved by Empirersquos Medical Management Program (for in-network physical therapy only) Designed to improve or restore physical functioning within a reasonable period of time

Outpatient care must be given at home in a therapistrsquos office or in an outpatient facility by an in-network provider inpatient therapy must be short-term

x Occupational speech or vision therapy or any combination of these on an outpatient basis up to the plan maximums if Prescribed by a physician or in conjunction with a physicianrsquos services Given by skilled medical personnel at home in a therapistrsquos office or in an outpatient facility Performed by a licensed speechlanguage pathologist or audiologist

Whatrsquos Not Covered The following therapy services are not covered

x Therapy to maintain or prevent deterioration of the patientrsquos current physical abilities x Tests evaluations or diagnoses received within the 12 months prior to the doctorrsquos referral or order for occupational

speech or vision therapy

wwwempirebluecom 29

Behavioral Healthcare IF YOU NEED BEHAVIORAL HEALTHCARE

At Empire we realize that your mental health is as important as your physical health Thatrsquos why we include behavioral healthcare benefits at little out-of-pocket cost Your behavioral healthcare benefits cover outpatient treatment for alcohol or substance abuse both in-network and out-of-network and inpatient detoxification in-network and out-of-network Inpatient alcohol and substance abuse rehabilitation in a facility is covered in-network and out-of-network Mental healthcare is covered on an inpatient basis in-network and out-of-network and on an outpatient basis in-network and out-of-network

Please note that with the exception of outpatient alcohol and substance abuse treatment the coinsurance that you pay for out-of-network behavioral healthcare services will not count toward reaching your annual out-of-pocket limit

Please refer to the Health Management section for details regarding precertification requirements

Mental Health Care

Whatrsquos Covered In addition to the services listed in Your Benefits at a Glance section the following mental health care service is covered

x Electroconvulsive therapy for treatment of mental or behavioral disorders if precertified by Behavioral Healthcare Management

x Care from psychiatrists psychologists nurse practitioners or licensed clinical social workers providing psychiatric or psychological services within the scope of their practice including the diagnosis and treatment of mental and behavioral disorders Social workers must be licensed by the New York State Education Department or a comparable organization in another state and have three years of post-degree supervised experience in psychotherapy and an additional three years of post-licensure supervised experience in psychotherapy

x Treatment in a New York State Health Department-designated Comprehensive Care Center for Eating Disorders pursuant to Article 27-J of the New York State Public Health Law

x We Cover inpatient mental health care services relating to the diagnosis and treatment of mental nervous and emotional disorders received at Facilities that provide room and board charges

Whatrsquos Not Covered The following mental health care services are not covered

x Care that is not medically necessary x Out-of-network inpatient mental health care at a facility that is not an acute care general hospital x Residential treatment services

Treatment for Alcohol or Substance Abuse

Whatrsquos Covered In addition to the services listed in Your Benefits at a Glance section the following services are covered

x Family counseling services at an outpatient treatment facility These can take place before the patientrsquos treatment begins Any family member covered by the plan may receive one counseling visit per day

x Visits for family counseling are deducted from the 60 visits available for outpatient treatment x Out-of-network outpatient treatment at a facility that

Has New York State certification from the Office of Alcoholism and Substance Abuse Services Is approved by the Joint Commission on the Accreditation of Health Care Organizations if out of state The

program must offer services appropriate to the patientrsquos diagnosis

Whatrsquos Not Covered The following alcohol and substance abuse treatment services are not covered

x Out-of-network outpatient alcohol or substance abuse treatment at a facility that does not meet Empirersquos certification requirements as stated above

x Care that is not medically necessary x Out-of-network inpatient alcohol or substance abuse rehabilitation at a facility that is not an acute care general

hospital x Out-of-network inpatient detoxification at a facility that is not an acute care general hospital x Residential treatment services

30 wwwempirebluecom

Empirersquos Pharmacy Program YOUR PHARMACY BENEFITS PROGRAM

Empire understands that filling prescriptions can be costly To help reduce your costs Empire offers the pharmacy program Your Empire pharmacy program covers most drugs as long as they have been prescribed by a physician and approved by the Federal Drug Administration (FDA) You can choose whether to fill your prescription at a network pharmacy or through the mail order program

FILLING A PRESCRIPTION When you have a prescription filled you must pay the pharmacy the cost share amount for each separate prescription or refill We will pay the pharmacy directly for the remainder of the cost of the prescription or refill The Maximum Allowed Amount for covered Prescription Drugs is the amount determined by us using prescription drug cost information provided by the Pharmacy Benefits Manager (PBM) The amount of the cost share for your prescription drug coverage is listed in Your Benefits At A Glance chart

EMPIRErsquoS DRUG FORMULARY Empire uses a preferred drug formulary which is a list of generic and preferred brand drugs that is distributed to participating pharmacies and providers and is subject to periodic review and modification by Us Your doctor is encouraged to prescribe generic-equivalent drugs as appropriate when possible and to prescribe drugs from the preferred drug formulary when prescribing brand-name drugs

The Preferred Formulary has three tiers

Tier 1 drugs generally have the lowest Cost Share This tier contains preferred medications that are generic single source brand drugs or multi-source brand drugs Tier 2 drugs generally have a higher Cost Share than those in Tier 1 This tier contains preferred medications that are generic single source brand drugs or multi-source brand drugs Tier 3 drugs generally have a higher Cost Share than those on Tier 2 This tier contains non-preferred medications that are generic single source brand drugs or multi-source brand drugs

Preferred Generics For most Prescription Drugs You pay only the Cost-Sharing in the Your Benefits at a Glance section of the booklet An additional charge called an ldquoancillary chargerdquo may apply to some Prescription Drugs when a Prescription Drug on a higher tier is dispensed at You or Your Providerrsquos request and Our formulary includes a chemically equivalent Prescription Drug is available on a lower tier You will have to pay the difference between the full cost of the Prescription Drug on the higher tier and the cost of the Prescription Drug on the lower tier The cost difference is not Covered and must be paid by You in addition to the lower tier Cost-Sharing Your Cost-Sharing will never exceed the Usual and Customary Charge of the Prescription Drug Note Prescription Drugs will always be dispensed as ordered by your Doctor You may ask for or your Doctor may order the Brand Name Drug However if a Generic Drug is available you will have to pay the difference in the cost between the Generic and Brand Name Drug as well as your Tier 1 Copayment Coinsurance By law Generic and Brand Name Drugs must meet the same standards for safety strength and effectiveness Using generics generally saves money yet gives the same quality For certain higher cost generic drugs we reserve the right in our sole discretion to make an exception and not require you to pay the difference in cost between the Generic and Brand Name Drug

wwwempirebluecom 31

You are responsible for paying the full cost (the amount the pharmacy charges You) for any non-Covered Prescription Drug and Our contracted rates (Our Prescription Drug Cost) will not be available to You Tier Assignment Process Empirersquos Pharmacy and Therapeutics (PampT) Committee consists of health care professionals including nurses pharmacists and physicians The purpose of this committee is to assist in determining clinical appropriateness of drugs determining the tier assignments of drugs and advising on programs designed to help improve delivery of care Such programs may include drug utilization programs prior authorization criteria therapeutic conversion programs and drug profiling initiatives The determination of tiers is made based upon clinical decisions provided by the PampT Committee and where appropriate the cost of the Drug relative to other Drugs in its therapeutic class or used to treat the same or similar condition the availability of over-the-counter alternatives and where appropriate certain clinical economic factors Empire retains the right to determine coverage for dosage formulations in terms of covered dosage administration methods (for example by mouth injections topical or inhaled) and may cover one form of administration and exclude or place other forms of administration on another Tier The formulary and procedures are made available to all network providers at least once a year or sooner if there are changes

SPECIALTY DRUGS You or your Physician are required to order your Specialty Drugs directly from a Network Specialty Pharmacy ldquoSpecialty Drugsrdquo are prescription drugs which

x Are approved to treat limited patient populations indications or conditions x Are normally injected infused or require close monitoring by a physician or clinically trained individual or x Have limited availability special dispensing and delivery requirements andor require additional patient support any

or all of which make the drug difficult to obtain through traditional pharmacies

Network Specialty Pharmacies may fill both retail and mail service Specialty Drug prescription orders up to a thirty (30) day supply for retail and mail service and subject to the applicable Deductible Coinsurance or Copayment shown in the Your Benefits At A Glance chart

Network Specialty Pharmacies have dedicated patient care coordinators to help you obtain prior authorization if applicable manage your condition and offer toll-free twenty-four hour access to nurses and registered pharmacists to answer questions regarding your medications

You may obtain a list of the Network Specialty Pharmacies and covered Specialty Drugs by calling the Customer Service telephone number on the back of your ID card or review the lists on our website at wwwempirebluecom select ldquoPharmacyrdquo under the ldquoPlans and Benefitsrdquo tab of the ldquoMember Homerdquo page

In addition certain drugs that must be administered by a physician or other authorized practitioner are required to be ordered from our Network Specialty Pharmacy in order to be covered as a medical benefit If you require one of these drugs your physician or other treating practitioner will order the drug from the required pharmacy You will not be required to fill a prescription for this category of drug

SPECIAL PROGRAMS From time to time we may initiate various programs to encourage Covered Persons to utilize more cost-effective or clinically-effective drugs including but not limited to generic drugs mail order drugs over the counter (OTC) or preferred products Such programs may involve reducing or waiving Copayments or Coinsurance for certain drugs or preferred products for a limited period of time

REMEMBER Benefits are only available for prescriptions filled at network pharmacies or through Empirersquos mail order

NETWORK PHARMACY You must fill a prescription at an Empire network pharmacy for up to a 34-day supply of FDA-approved drugs if prescribed by a physician or other licensed provider Empirersquos pharmacy program offers

x Low cost You can receive up to a 34-day supply for each drug for a single co-payment x Convenience You must present your Empire ID card to the pharmacist along with your prescription Thatrsquos all you

need to get the cost advantages of this program x No claim forms Under your policy guidelines paper claims cannot be submitted The pharmacist must submit your

claim when you fill the prescription

32 wwwempirebluecom

Tip for Using a Network Pharmacy To locate a network pharmacy check the list of national chain pharmacies you received with your ID card For information about network pharmacies that are not a part of a national chain log on to wwwempirebluecom and click on the Rx icon on your home page or call Empirersquos pharmacy program at 1-800-342-9816 You can also call when you are away from home for the name and location of the nearest participating pharmacy

REMEMBER A pharmacist is not required to fill a prescription that in the pharmacistrsquos professional judgment should not be filled

SAVE MONEY WITH EMPIRErsquoS MAIL ORDER PRESCRIPTIONS Certain Prescription Drugs may be ordered through our mail order pharmacy You can reduce your drug co-payments by using Empirersquos pharmacy mail order because you can receive up to a 90-day (three-month) supply of your medication on a single prescription for only one co-payment This service is ideal for members who take the same medication on an on-going basis The same prescriptions filled at a participating pharmacy cost three co-payments for a three-month supply of medicationmdashone co-payment for each 34-day supply In addition Empire waives drug deductibles when you use the mail order Deductibles still apply if you fill your prescriptions at a pharmacy Home Delivery for Maintenance Medications ndash If you are taking a Maintenance Medication you may get the first 30-day supply and two 30-day refills of the same Maintenance Medication at your local Retail Pharmacy You must then contact the Home Delivery Pharmacy and tell them if you would like to keep getting your 30-day supply of Maintenance Medications from your local Retail Pharmacy or if you would like to use the Home Delivery Pharmacy You will have to pay the full retail cost of any Maintenance Medication you get without registering your choice through the Home Delivery Pharmacy You can tell us your choice by phone at the number on the back of your ID Card or by visiting our website

How to Order Your Prescription by Mail x Ask your doctor to write a prescription for each of your medication(s) that covers a 90-day supply as well as three

refills (Example If you take 2 pills per day the prescription should be written for 180 pills plus three refills) x Complete the mail order form you received in the mail with your ID card(s) You can get additional forms by going

to wwwempirebluecom or calling Empirersquos pharmacy program at the number on the back of your member ID card x Place your order for a refill at least three weeks before your current supply will run out x You will receive your filled prescription at your home within 14 working days postage paid If you prefer you can

also choose faster shipping for an additional fee

Tips for Using Mail Order The first time you fill a prescription through mail order ask your physician for a second prescription for a four-week supply You can fill the second prescription at a local pharmacy so you have the medication until the mail order is processed

MANAGE YOUR PHARMACY PLAN ONLINE Taking care of your pharmacy needs is easier than ever with Empirersquos online pharmacy If yoursquore registered for Online Member Services just go to wwwempirebluecom where you can

x Search Empirersquos drug formulary for a particular drug (by name or therapeutic category) x Locate a participating retail pharmacy near where you live or work x Order prescription refills through the mail order program x Research usage instructions drug interactions and side effects for thousands of medications

Simply log on to our web site and access your own personal secure home page Click on ldquoMy Pharmacy Planrdquo which is right next to the Rx symbol under ldquoYour Health Planrdquo

Empirersquos Pharmacy Program Customer Service 1-800-342-9816 Whatrsquos Covered The following prescription drugs are covered x Insulin and self-administered injectables x Diabetic supplies x Enteral formulas for home use that are medically

necessary and proven effective for the specific disease when prescribed by a written order by a physician or other health care provider licensed to prescribe under applicable law

x Nutritional supplements when medically necessary and proven effective for treatment

x Contraceptive drugs or devices and diaphragms x Bone mineral density drugs and devices x Refills for up to one year from the date of the original

prescription if authorized by the physician and indicated on the prescription

x Smoking cessation products by prescription only

wwwempirebluecom 33

Whatrsquos Not Covered The following items are not covered x Drugs or devices that do not require a prescription or are available over the counter except insulin and diabetic supplies x Devices of any type such as therapeutic devices IUDrsquos artificial appliances hypodermic needles syringes or similar

devices except where specifically covered and except for bone density testing and treatment devices x Charges or fees for drug administration or injection x Vitamins that by law do not require a prescription x Investigational or experimental drugs (ie medications used for experiments andor dosage levels determined by Empire

to be experimental) Refer to the Exclusions and Limitations Section and also the Complaints Appeals and Grievances Section

34 wwwempirebluecom

x Drugs received while in a hospital nursing home or other facility (covered under medical plan as indicated) x Appetite suppressants unless medically necessary x Compounded medications with no ingredients that require a prescription x Medications for cosmetic purposes only x Medications not approved by the FDA unless otherwise required by law (ie drugs that have been prescribed for the

treatment of a type of cancer for which the drug has not been approved by the FDA and not considered investigational or experimental)

x Replacement of lost stolen or damaged prescription medications x The cost for medication in excess of plan limits x Refills not dispensed in accordance with the prescription x Refills beyond one year from the original prescription date

wwwempirebluecom 35

SCHEDULE A1

Drugs Subject to Prior Authorization

Drug Class Prescription Drug

Pain Relief Abstral Arthritis Actemra Pain Relief Actiq Pulmonary Arterial Hypertension Adcirca Cancer Treatment Afinitor Psoriasis Amevive Multiple Sclerosis Ampyra Hormonal Therapy Androderm Hormonal Therapy Androgel Blood Builder Aranesp Hormonal Therapy Arixion Cancer Treatment Avastin Cervical DystoniaSpasticity Botox Immune SystemImmune Globulin Carimune NF Gaucherrsquos Disease Ceredase Gaucherrsquos Disease Cerezyme ArthritisCrohns Disease Cimzia Cervical DystoniaSpasticity Dysport Cancer Treatment Eligard ArthritisPsoriasis Enbrel Blood Builder Epogen Cancer Treatment Erbitux Arthritis Euflexxa Pain Relief Fentora Immune SystemImmune Globulin Flebogamma Pulmonary Arterial Hypertension Flolan Osteporosis Forteo Hormonal Therapy Fortesta Immune SystemImmune Globulin Gamastan Immune SystemImmune Globulin Gammagard liquid SD Immune SystemImmune Globulin Gamunex Multiple Sclerosis Gilenya Cancer Treatment Gleevac Cancer Treatment Herceptin ArthritisCrohnsPsoriasis Humira Arthritis Hyalgan Immune Deficiency Increlex Hepatitis Infergen Hepatitis Intron-A Arthritis Kineret Infection Prevention and Treatment Lamisil Blood Builder Leukine Cancer TreatmentInfertility Leuprolide Macular Degeneration Lucentis Endometriosis InfertilityCancer Lupron Depot SeizuresFibromyalgiaNerve Pain Lyrica Macular Degeneration Macugen Cervical DystoniaSpasticity Myobloc Blood Builder Neulasta Blood Builder Neumega Blood Builder Neupogen Cancer Treatment Nexavar

36 wwwempirebluecom

SCHEDULE A1 (continued)

Drugs Subject to Prior Authorization

Drug Class Prescription Drug

Excessive Sleepiness Nuvigil Immune SystemImmune Globulin Octagam Cancer Treatment Oforta Pain Relief Onsolis Arthritis Orencia Arthritis Orthovisc Immune SystemImmune Globulin Panglobulin Hepatitis Pegasys Hepatitis Peg-Intron Infection Prevention and Treatment Penlac Immune SystemImmune Globulin Polygam SD Immune SystemImmune Globulin Privigen Blood Builder Procrit Osteporosis Prolia Excessive Sleepiness Provigil Infection Prevention and Treatment Qualaquin ArthritisCrohnsPsoriasis Remicade Pulmonary Arterial Hypertension Remodulin Pulmonary Arterial Hypertension Revatio Cancer Treatment Revlimid Cancer Treatment Rituxan Hepatitis Roferon-A ArthritisPsoriasis Simponi Excessive Sleepiness Sporanox Infection Prevention and Treatment Sprycel ArthritisCrohnsPsoriasis Stelara Opiod Dependence Suboxone Arthritis Supartz Precocious Puberty Supprelin LA Cancer Treatment Sutent RSV Prevention Synagis Precocious PubertyEndometriosis Synarel Arthritis Synvisc Arthritis Synvisc One Cancer Treatment Tarceva Cancer Treatment Targretin Cancer Treatment Tasigna Cancer Treatment Temodar Hormonal Therapy Testim Cancer Treatment Thalomid Cancer Treatment Trelstar Depot LA Cancer Treatment Tykerb Pulmonary Arterial Hypertension Tyvaso Cancer Treatment Vantas Implant Cancer Treatment Vectibix Pulmonary Arterial Hypertension Ventavis Infection Prevention and Treatment Vfend Immune SystemImmune Globulin Vivaglobin Addiction Treatment Vivitrol Cancer Treatment Votrient Gaucherrsquos Disease Vpriv Cancer Treatment Xeloda

wwwempirebluecom 37

SCHEDULE A1 (continued)

Drugs Subject to Prior Authorization

Drug Class Prescription Drug

Huntingtons Disease Xenazine Bone FracturePain Due to Cancer Xgeva Arthritis Xiaflex Antibiotic Xifaxan Asthma Xolair Gaucherrsquos Disease Zavesca Cancer Treatment Zoladex Cancer Treatment Zolinza Infection Prevention and Treatment Zyvox

38 wwwempirebluecom

SCHEDULE A2

Step Therapy Drugs Subject to Prior Authorization

Drug Class Prescription Drug

Proton Pump Inhibitor Aciphex Antiacne Adoxa Antiallergy-opthalmic Alamast Non-Sedating Antihistamine Allegra ODT Suspension D Antiallergy-opthalmic Alocril Antiallergy-opthalmic Alomide Antihyperlipidemic Altoprev SedativeHypnotics Ambien CR CNS Stimulant Amphetamine Salt Combo Hypoglycemics Apidra Non-Steroidal Antiinflammatories Arthrotec Diabetes Avandament Diabetes Avandaryl Diabetes Avandia Migraine Medication Axert Diabetes Blood Glucose MetersStrips Nasal Steroids Beconase AQ Antiacne - Topical Benzaclin Multiple Sclerosis Betaseron Osteoporosis Boniva Ovulatory Stimulants Bravelle Hypoglycemics Byetta Non-Steroidal Antiinflammatories Celebrex Non-Sedating Antihistamine Clarinex-D Non-Sedating Antihistamine Clarinex Suspension Proton Pump Inhibitor Dexilant Antiacne Doryx SedativeHypnotics Edluar Antiallergy-opthalmic Elestat Dermatological Agent Elidel Antiallergy-opthalmic Emadine Overactive Bladder Agents Enablex Multiple Sclerosis Extavia Analgesics Flector Nasal Steroids Flunisolide Nasal Spray Overactive Bladder Agents Gelnique Ovulatory Stimulants Gonal-F Proton Pump Inhibitors Kapidex Antihyperlipidemic Lescol XL Antihypertensive Letairis Antihyperlipidemic Livalo Antiacne Minocin Nasal Steroids Nasacort AQ Nasal Steroids Nasarel Nasal Steroids Omnaris Antiallergy-opthalmic Optivar Overactive Bladder Agents Oxytrol Proton Pump Inhibitors pantaprazole Proton Pump Inhibitors Prilosec Proton Pump Inhibitors Prevacid Proton Pump Inhibitors Protonix Dermatological Agent Protopic

wwwempirebluecom 39

SCHEDULE A2

Step Therapy Drugs Subject to Prior Authorization (continued)

x

Drug Class Prescription Drug

Migraine Medication Relpax Nasal Steroids Rhinocort Aqua SedativeHypnotics Rozerem Antiacne Solodyn Overactive Bladder Agents Sanctura SedativeHypnotics Sonata Migraine Medication Sumavel DosePro Migraine Medication Treximet Gout Medications Uloric Hypoglycemics Victoza Antihyperlipidemics Vytorin Non-Sedating Antihistamine Xyzal Syrup Proton Pump Inhibitors Zegerid Antihyperlipidemics Zetia Skin Condition Ziana Sleep Aid Zolpimist

40 wwwempirebluecom

Exclusions and Limitations EXCLUSIONS

In addition to services mentioned under ldquoWhatrsquos Not Coveredrdquo in the prior sections your plan does not cover the following

Dental Services x Dental services including but not limited to

Cavities and extractions Care of gums Bones supporting the teeth or periodontal

abscess Orthodontia

False teeth Treatment of TMJ that is dental in nature Orthognathic surgery that is dental in nature

However your plan does cover

x Surgical removal of impacted teeth x Treatment of sound natural teeth injured by accident if treated within 12 months of the injury

ExperimentalInvestigational Treatments x Technology treatments procedures drugs biological products or medical devices that in Empirersquos judgment are

Experimental or investigative Obsolete or ineffective x Any hospitalization in connection with experimental or investigational treatments ldquoExperimentalrdquo or ldquoinvestigativerdquo

means that for the particular diagnosis or treatment of the covered personrsquos condition the treatment is Not of proven benefit Not generally recognized by the medical community (as reflected in published medical literature)

Government approval of a specific technology or treatment does not necessarily prove that it is appropriate or effective for a particular diagnosis or treatment of a covered personrsquos condition Empire may require that any or all of the following criteria be met to determine whether a technology treatment procedure biological product medical device or drug is experimental investigative obsolete or ineffective

x (FDA Approval) for the patientrsquos particular diagnosis or condition except for certain drugs prescribed for the treatment of cancer Once the FDA approves use of a medical device drug or biological product for a particular diagnosis or condition use for another diagnosis or condition may require that additional criteria be met

x Published peer review medical literature must conclude that the technology has a definite positive effect on health outcomes

x Published evidence must show that over time the treatment improves health outcomes (ie the beneficial effects outweigh any harmful effects)

x Published proof must show that the treatment at the least improves health outcomes or that it can be used in appropriate medical situations where the established treatment cannot be used Published proof must show that the treatment improves health outcomes in standard medical practice not just in an experimental laboratory setting

However your plan will cover an experimental or investigational treatment approved by an External Appeal agent certified by the state Refer to the Complaints Appeals and Grievances Section

Government Services x Services covered under government programs except Medicaid or where otherwise noted x Government hospital services except

Specific services covered in a special agreement between Empire and a government hospital United States Veteransrsquo Administration or Department of Defense Hospitals except services in connection with

a service-related disability In an emergency Empire will provide benefits until the government hospital can safely transfer the patient to a participating hospital

Home Care x Services performed at home except for those services specifically noted elsewhere in this Guide as available either at

home or as an emergency

wwwempirebluecom 41

Inappropriate Billing x Services usually given without charge even if charges are billed x Services performed by hospital or institutional staff which are billed separately from other hospital or institutional

services except as specified

Medically Unnecessary Services x Services treatment or supplies not medically necessary in Empirersquos judgment See Definitions section for more

information

Not Medically Necessary Transgender Surgery x Surgery andor treatment for gender change that does not meet our medical criteria for medical necessity

Prescription Drugs x All over the counter drugs vitamins appetite suppressants or any other type of medication unless specifically

indicated

Services Provided by a Family Member x We do not Cover services performed by a member of the covered personrsquos immediate family ldquoImmediate familyrdquo

shall mean a child spouse mother father sister or brother of You or Your Spouse

SterilizationReproductive Technologies x Reversal of sterilization x Assisted reproductive technologies including but not limited to

In-vitro fertilization Artificial insemination

Gamete and zygote intrafallopian tube transfer Intracytoplasmic sperm injection

Travel x Travel even if associated with treatment and recommended by a doctor

Vision Care x Eyeglasses contact lenses [and the examination for their fitting] except following cataract surgery unless

specifically indicated

War x Services for illness or injury received as a result of war

Workersrsquo Compensation x Services covered under Workersrsquo Compensation no-fault automobile insurance andor services covered by similar

statutory programs

LIMITATION AS INDEPENDENT CONTRACTOR The relationship between Empire BlueCross BlueShield and hospitals facilities or providers is that of independent contractors Nothing in this contract shall be deemed to create between Empire and any hospital facility or provider (or agent or employee thereof) the relationship of employer and employee or of principal and agent Empire will not be liable in any lawsuit claim or demand for damages incurred or injuries that you may sustain resulting from care received either in a hospitalfacility or from a provider

42 wwwempirebluecom

Health Management Empirersquos Medical Management Program Managing your health includes getting the information you need to make informed decisions and making sure you get the maximum benefits the plan will pay To help you manage your health Empire provides the Empirersquos Medical Management Program a service that precertifies hospital admissions and certain treatments and procedures to help ensure that you receive the highest quality of care for the right length of time in the right setting and with the maximum available coverage Empirersquos Medical Management Program works with you and your provider to help confirm the medical necessity of services and help you make sound health care decisions The program helps ensure that you and your family members receive the highest quality of care at the right time in the most appropriate setting You can contact our Medical Management program by calling the Member Services telephone number located on the back of your identification card Empire may from time to time waive enhance modify or discontinue certain medical management processes (including utilization management case management and disease management) if in Empirersquos discretion such change is in furtherance of the provision of cost effective value based andor quality services In addition we may select certain qualifying Providers to participate in a program that exempts them from certain procedural or medical management processes that would otherwise apply We may also exempt your Claim from medical review if certain conditions apply Just because Empire exempts a process Provider or Claim from the standards which otherwise would apply it does not mean that Empire will do so in the future or will do so in the future for any other Provider Claim or Member Empire may stop or modify any such exemption with or without advance notice You may determine whether a Provider is participating in certain programs by checking your on-line Provider Directory or contacting customer service number on the back of your ID card

HOW EMPIRErsquoS MEDICAL MANAGEMENT PROGRAM HELPS YOU To help ensure that you receive the maximum coverage available to you Empirersquos Medical Management Program

x Reviews all planned and emergency hospital admissions x Reviews ongoing hospitalization x Performs case management x Coordinates discharge planning x Coordinates purchase and replacement of durable medical equipment prosthetics and orthotic requirements x Reviews inpatient and ambulatory surgery x Reviews high-risk maternity admissions x Reviews care in a hospice or skilled nursing or other facility

All other services will be subject to retrospective review by our Medical Management team to determine medical necessity The health care services on the following page must be precertified with Empirersquos Medical Management Program

wwwempirebluecom 43

CALL TO PRECERTIFY THE REQUIRED SERVICEShellip

FOR ALL HOSPITAL ADMISSIONS

x At least two weeks prior to any planned surgery or hospital admission x Within 48 hours of an emergency hospital admission or as soon as reasonably possible x Of newborns for illness or injury x Before you are admitted to a rehabilitation facility or a skilled nursing facility

MATERNITY CARE

x As soon as reasonably possible we request notification within the first three months of pregnancy when possible x Within 48 hours after the actual delivery date if stay is expected to extend beyond the minimum length of stay for

mother and newborn inpatient admission forty-eight (48) hours for a vaginal birth or ninety-six (96) hours for cesarean birth

BEFORE YOU RECEIVEUSE

x Inpatient Mental Health Care Substance Abuse Care and Alcohol Detoxification x Partial Hospital Programs Psychological Testing Intensive Outpatient Programs x Occupational physical speech and vision therapy x Outpatient Ambulatory Surgical Treatments (certain procedures) x Diagnostics x Outpatient Treatments x Durable medical equipment x Air ambulance

IF SERVICES ARE NOT PRECERTIFIED If you call to precertify services as needed you will receive maximum benefits Otherwise benefits may be reduced by 50 up to $2500 for each admission treatment or procedure This benefit reduction also applies to certain same-day surgery and professional services rendered during an inpatient admission If the admission or procedure is not medically necessary no benefits will be paid

1 Preauthorization Reviews

a Non-Urgent Preauthorization Reviews If We have all the information necessary to make a determination regarding a Preauthorization review We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of receipt of the request

If We need additional information We will request it within fifteen (15) calendar days You or Your Provider will then have 45 calendar days to submit the information If We receive the requested information within 45 days We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of Our receipt of the additional information If all necessary information is not received within 45 days We will make a determination within 15 calendar days of the end of the 45 day period allowed to submit the additional information

b Urgent Preauthorization Reviews With respect to urgent Preauthorization requests if We have all

information necessary to make a determination We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within 72 hours of receipt of the request If We need additional information We will request it within 24 hours You or Your Provider will then have 48 hours to submit the information We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within 48 hours of the earlier of Our receipt of the additional information or the end of the 48-hour period allowed to submit additional information

c Court Ordered Treatment With respect to requests for mental health andor substance use disorder

services that have not yet been provided if You (or Your designee) certify in a format prescribed by the Superintendent of Financial Services that You will be appearing or have appeared before a court of competent jurisdiction and may be subject to a court order requiring such services We will make a

44 wwwempirebluecom

determination and provide notice to You (or Your designee) and Your Provider by telephone within 72 hours of receipt of the request Written notification will be provided within three (3) business days of Our receipt of the request Where feasible the telephonic and written notification will also be provided to the court

2 Concurrent Reviews

1 Non-Urgent Concurrent Reviews Utilization Review decisions for services during the course of care (concurrent reviews) will be made and notice provided to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of receipt of all necessary information If We need additional information We will request it within fifteen (15) calendar days of the receipt of the request You or Your Provider will then have 45 calendar days to submit the additional information We will make a determination and provide notice to You (or Your designee) and Your Provider in writing within fifteen (15) calendar days of Our receipt of the additional information or if We do not receive the information within 15 calendar days of the end of the 45-day period allowed to provide the additional information

2 Urgent Concurrent Reviews For concurrent reviews that involve an extension of urgent care if the

request for coverage is made at least 24 hours prior to the expiration of a previously approved treatment We will make a determination and provide notice to You (or Your designee) and Your Provider within 24 hours of receipt of the request If the request for coverage is not made at least 24 hours prior to the expiration of a previously approved treatment We will make a determination and provide written notice to You (or Your designee) and Your Provider within 72 hours of receipt of the request If We need additional information We will request it within 24 hours You or Your Provider will then have 48 hours to submit the information We will make a determination and provide written notice to You (or Your designee) and Your Provider within the earlier of one (1) business day or 48 hours of Our receipt of the information or if We do not receive the information within 48 hours of the end of the 48-hour period

3 Inpatient Substance Use Disorder Treatment Reviews If a request for inpatient substance use disorder treatment is submitted to Us at least 24 hours prior to discharge from an inpatient substance use disorder treatment admission We will make a determination within 24 hours of receipt of the request and We will provide coverage for the inpatient substance use disorder treatment while Our determination is pending

3 Retrospective Reviews If We have all information necessary to make a determination regarding a retrospective claim We will make a determination and notify You and Your Provider within 30 calendar days of the receipt of the request If We need additional information We will request it within 30 calendar days You or Your Provider will then have 45 calendar days to provide the information We will make a determination and provide notice to You and Your Provider in writing within 15 calendar days of the earlier of Our receipt of all or part of the requested information or the end of the 45-day period

Once We have all the information to make a decision Our failure to make a Utilization Review determination within the applicable time frames set forth above will be deemed an adverse determination subject to an internal Appeal

4 Retrospective Review of Preauthorized Services We may only reverse a preauthorized treatment service

or procedure on retrospective review when x The relevant medical information presented to Us upon retrospective review is materially different

from the information presented during the Preauthorization review x The relevant medical information presented to Us upon retrospective review existed at the time of the

Preauthorization but was withheld or not made available to Us x We were not aware of the existence of such information at the time of the Preauthorization review

and x Had We been aware of such information the treatment service or procedure being requested would

not have been authorized The determination is made using the same specific standards criteria or procedures as used during the Preauthorization review

5 Reconsideration If We did not attempt to consult with Your Provider who recommended the Covered

Service before making an adverse determination the Provider may request reconsideration by the same

wwwempirebluecom 45

clinical peer reviewer who made the adverse determination or a designated clinical peer reviewer if the original clinical peer reviewer is unavailable For Preauthorization and concurrent reviews the reconsideration will take place within one (1) business day of the request for reconsideration If the adverse determination is upheld a notice of adverse determination will be given to You and Your Provider and in writing

If Empirersquos Medical Management Program does not meet the above time frames the failure should be considered a denial You or your doctor may immediately appeal

IF A REQUEST IS DENIED All denials of benefits will be rendered by qualified medical personnel If a request for care or services is denied for lack of medical necessity or because the service has been determined to be experimental or investigational Empirersquos Medical Management Program will send a notice to you and your doctor with the reasons for the denial You will have the right to appeal See section in this booklet titled ldquoComplaints Appeals and Grievancesrdquo for more information

If Empirersquos Medical Management Program denies benefits for care or services without discussing the decision with your doctor your doctor is entitled to ask Medical Management to reconsider their decision A response will be provided by telephone and in writing within one business day of making the decision

46 wwwempirebluecom

New Medical Technology REQUESTING COVERAGE

Empire uses a committee composed of Empire Medical Directors who are doctors and participating network physicians to continuously evaluate new medical technology that has not yet been designated as a covered service If you want to request certification of a new medical technology before beginning treatment your provider must contact Empirersquos Medical Management Program The provider will be asked to do the following

x Provide full supporting documentation about the new medical technology x Explain how standard medical treatment has been ineffective or would be medically inappropriate x Send us scientific peer reviewed literature that supports the effectiveness of this particular technology The literature

must not be in the form of an abstract or individual case study Empirersquos staff will evaluate the proposal in light of your contract and Empirersquos current medical policy Empire will then review the proposal taking into account relevant medical literature including current peer review articles and reviews Empire may use outside consultants if necessary If the request is complicated Empire may refer your proposal to a multi-specialty team of physicians or to a national ombudsman program designed to review such proposals Empire will send all decisions to the member andor provider

Case Management IF YOU NEED ADDITIONAL SUPPORT FOR SERIOUS ILLNESS

The Medical Management Programrsquos Case Management staff can provide assistance and support when you or a member of your family faces a chronic or catastrophic illness or injury Empirersquos nurses can help you and your family

x Find appropriate cost-effective healthcare options x Reduce medical cost x Assure quality medical care

A Case Manager serves as a single source for patient provider and insurer ndash assuring that the treatment level of care and facility are appropriate for your needs For example Case Management can help with cases such as x Cancer x Stroke x AIDS

x Chronic illness x Hemophilia x Spinal cord and other traumatic injuries

Assistance from Case Management is evaluated and provided on a case-by-case basis In some situations Empirersquos Medical Management Program staff will initiate a review of a patients health status and the attending doctors plan of care They may determine that a level of benefits not necessarily provided by this plan is desirable appropriate and cost-effective If you would like Case Management assistance following an illness or surgery contact Empirersquos Medical Management Program at 1-800-982-8089

wwwempirebluecom 47

Preventive Services Preventive Care services include Outpatient services and Office Services Screenings and other services are covered as Preventive Care for adults and children with no current symptoms or prior history of a medical condition associated with that screening or service Members who have current symptoms or have been diagnosed with a medical condition are not considered to require Preventive Care for that condition but instead benefits will be considered under the Diagnostic Services benefit Preventive Care Services in this section shall meet requirements as determined by federal law Many Preventive Care Services are covered by this Benefit Program with no Deductible Copayments or Coinsurance from the Member when provided by a Network Provider These services fall under four broad categories as shown below A Items or services with an ldquoArdquo or ldquoBrdquo rating from the United States Preventive Services Task Force

Examples of these services are screenings for Breast cancer Cervical cancer Colorectal cancer High blood pressure Type 2 diabetes mellitus Cholesterol Child and adult obesity

B Immunizations pursuant to the Advisory Committee on Immunization Practices (ldquoACIPrdquo) recommendations including

the well-child care immunizations as listed below

x DPT (diphtheria pertussis and tetanus)

x Polio

x MMR (measles mumps and rubella)

x Varicella (chicken pox)

x Hepatitis B Hemophilus

x Tetanus-diphtheria

x Pneumococcal

x Meningococcal Tetramune

x Other immunizations as determined by the Superintendent of Insurance and the Commissioner of Health in New York State or the state where your child lives

C Preventive care and screenings that are provided for in the comprehensive guidelines supported by the Health Resources

and Services Administration (ldquoHRSArdquo) including

x Well-child care visits to a pediatrician nurse or licensed nurse practitioner including a physical examination medical history developmental assessment and guidance on normal childhood development and laboratory tests The tests may be performed in the office or a laboratory Covered services and the number of visits covered per year are based on the prevailing clinical standards of the American Academy of Pediatrics (AAP) and will be determined by your childrsquos age

x Bone Density Testing and Treatment Standards for determining appropriate coverage include the criteria of the

federal Medicare program and the criteria of the National Institutes of Health for the Detection of Osteoporosis Bone mineral density measurements or tests drugs and devices include those covered under Medicare and in accordance with the criteria of the National Institutes of Health including as consistent with such criteria dual energy X-ray absorptiometry Coverage shall be available as follows

For individuals who are Ages 52 through 65 - 1 baseline Age 65 and older - 1 every 2 years (if baseline before age 65 does not indicate osteoporosis)

48 wwwempirebluecom

Under Age 65 - 1 every 2 years (if baseline before age 65 indicates osteoporosis)

For individuals who meet the criteria of the above programs including one or more of the following Previously diagnosed with or having a family history of osteoporosis Symptoms or conditions indicative of the presence or significant risk of osteoporosis Prescribed drug regimen posing a significant risk of osteoporosis Lifestyle factors to such a degree posing a significant risk of osteoporosis Age gender andor other physiological characteristics that pose a significant risk of osteoporosis

D Womenrsquos Preventive Additional preventive care and screenings for women provided for in the guidelines supported by

the Health Resources and Services Administration including the following x Well-woman care visits to a gynecologistobstetrician x Women with no prior or family history of breast cancer get a baseline mammogram between ages 35-39 and for

ages 40 and over an annual mammogram Women who have a family history of breast cancer will be covered for a routine mammogram at any age and as often as their physician recommends one

x Womenrsquos contraceptives sterilization procedures and counseling This includes contraceptive devices such as

diaphragms intra uterine devices (IUDs) and implants as well as injectable contraceptives In addition coverage is available for generic and single-source brand name prescription drugs for oral contraceptives and patches dispensed from a pharmacy To obtain benefits prescription drugs must be approved by the federal Food and Drug Administration and must be obtained from a retail or mail order pharmacy that is a member of our Pharmacy Network Please see the Oral Contraceptive Prescription Drug Rider for more information

x Breastfeeding support supplies and counseling Covered in full when received from an In-Network Provider Benefits for breast pumps are limited to one pump per Calendar Year

x Screenings andor counseling where applicable for Gestational diabetes Human Papillomavirus (HPV) sexually transmitted infections (STIs) Human immune-deficiency virus (HIV) and interpersonal and domestic violence

Screening for Prostate Cancer

We Cover an annual standard diagnostic examination including but not limited to a digital rectal examination and a prostate specific antigen test for men age 50 and over who are asymptomatic and for men age 40 and over with a family history of prostate cancer or other prostate cancer risk factors We also Cover standard diagnostic testing including but not limited to a digital rectal examination and a prostate-specific antigen test at any age for men having a prior history of prostate cancer This benefit is not subject to Copayments Deductibles or Coinsurance when provided by a Participating Provider The preventive services referenced above shall be covered in full when received from In-Network Providers Cost sharing (eg Copayments Deductibles Coinsurance) may apply to services provided during the same visit as the preventive services set forth above For example if a service referenced above is provided during an office visit wherein that service is not the primary purpose of the visit the cost-sharing amount that would otherwise apply to the office visit will still apply A list of the preventive services covered under this paragraph is available on our website at wwwempirebluecom or will be mailed to you upon request You may request the list by calling the Customer Service number on your identification card

VOLUNTARY CLINICAL QUALITY PROGRAMS The purpose of these voluntary clinical quality programs is to promote good health and early detection of disease They are designed to encourage eligible Members to obtain certain covered Preventive Care or other recommended care covered under this Certificate that was not received within the recommended timeframe For instance a program may be designed to encourage You to bring Your child to his or her PCP for a well-child or well-baby care visit if You missed a recommended check-up or may encourage You to get certain screening tests such as a mammogram if You have not been tested within the recommended age range Or a program may encourage You to have a medical visit within a specific time period such as a postpartum checkup within a set number of days after delivery of a newborn or a home visit so you can provide a blood sample for a recommended laboratory test

a Description These voluntary clinical quality programs are designed to encourage You to get certain preventive

wwwempirebluecom 49

wellness or other recommended care when You need it based on recommended clinical guidelines These programs are not guaranteed and Your participation is optional We will give You the choice and if You choose to participate in any program for which You qualify and obtain the recommended care within the programrsquos timeframe You will receive an incentive The incentive will take the form of

i a gift card in the amount of $50 or retailer coupons such as for discounts on eye glasses

ii a home test kit at no cost to allow you to conveniently collect a specimen for certain covered laboratory tests at home and mail it to the laboratory for processing In this case You may need to pay any cost shares that normally apply to covered laboratory tests under your benefit plan but the home test kit will be free to You or

iii a home visit to allow you to provide a specimen for certain covered laboratory tests or for certain biometric screenings In this care You may need to pay any cost shares that normally apply to covered laboratory tests but the home visit will be free to You

If you have any questions about whether receipt of a gift card or retailer coupon results in taxable income to You we recommend that you consult Your tax advisor

b Eligibility You the Subscriber and the Subscriberrsquos covered Spouse and each covered Dependent can

participate in the Voluntary Clinical Quality Program(s) if the targeted service applies based on the recommended clinical guidelines the program promotes These programs will be offered to Members who have certain conditions who fall within certain age ranges or who are due to receive certain recommended preventive or other care based on a recommended timeframe For example

i Members age 50-75 years who have not undergone colorectal cancer screening as recommended by the American Cancer Society may be eligible to participate in a program designed to encourage these members to obtain a recommended preventive colorectal cancer screening such as a fecal occult blood screening test

ii Members age 50-74 years who have not had a mammography screening as

recommended by the United States Preventive Services Task Force may be eligible to participate in a program designed to encourage these members to obtain the screening through the offer of a gift card awarded upon receipt of documentation that the screening was completed

c Participation If You are eligible for a clinical quality program we offer we will contact You by phone or mail to

offer You the chance to participate You may also call us at the phone number on Your ID card if You have any questions regarding program participation We will explain to You the care You are recommended to receive and the time frame within which You need to receive it to be in eligible for the reward if applicable

d Rewards Rewards for participation in a clinical quality program and completion of the identified services within the specified timeframe include monetary rewards in the form of a gift card or retailer coupon such as for discounts on eye glasses so long as the recipient is encouraged to use the reward for a product or service that promotes good health In other cases You will receive a home test kit at no cost to make it more convenient for You to receive the recommended care

50 wwwempirebluecom

Wellness Programs A Purpose The purpose of Our wellness program(s) is to encourage You to take a more active role in

managing Your health and well-being Our wellness-related programs are designed to help You achieve Your best health These programs are not Covered services under Your Plan but are separate components which are not guaranteed under Your Plan and could be discontinued at any time Participation is voluntary and You can discontinue the program at any time

B Description We provide benefits in connection with the use of or participation in any of the following wellness and health promotion actions and activities 1 Health Assessment Completion A Health Assessment is an online health tool You will answer

questions about Your lifestyle current health and history You will have access to a personal report with health tips and available online programs

x Eligibility The Subscriber and the Subscriberrsquos covered Spouse or Domestic Partner age 18 and older can participate in the program

x Participation To access the Health Assessment register or log in to Our website at wwwempirebluecom If You havenrsquot set up a user name and password select Register Now to set them up Then click on the Health amp Wellness tab and select ldquoTake my HA nowrdquo to complete the assessment On Your first visit to the site Yoursquoll be asked to give Your email address and choose health topics of interest If You do not have access to a computer please call Us at the number on Your ID card and We will provide You with information regarding how to participate without internet access We will provide You with a paper Health Assessment that will allow You to participate without computer access

2 Future Moms Future Moms is a maternity management program which provides individualized support

to expectant moms to help them achieve healthier pregnancies and deliveries The program provides education and support for high-risk and non-high-risk expectant mothers

x Eligibility The Subscriber and the Subscriberrsquos covered Spouse or Domestic Partner age 18 and older can participate in the program

x Participation Expectant moms can sign up and enroll by calling Us toll free at 800-828-5891 One of Our registered nurses will help You get started

3 Behavioral Health Resource Our Behavioral Health Resource program provides individualized support

from care managers to members with behavioral health conditions such as depression and anxiety Care managers are licensed mental health professionals whose goals are to help you take control of your health care and improve your quality of life Members have access to

x Our telephonic behavioral health resource center available 24 hours a day 7 days a week for assessment referral education coaching and crisis resolution including depression care management eating disorder management and management of other complex behavioral health concerns

x The programrsquos online and mobile app wellness tools These tools offer customized ways to address topics such as stress management anxiety depression substance abuse and chronic pain The program employs personalized tools evidence-based resources and individually-tailored eLearning programs to help members learn and practice new ways to manage their mental well-being

x Eligibility The Subscriber and each covered Dependent are eligible for the program x Participation You may call Us toll free at the number on Your ID card A care manager

will help You get started In addition We may use claims history to identify and contact potential candidates by phone to discuss whether the program is right for them

wwwempirebluecom 51

Details and Definitions In this section wersquoll cover the details you need to know to make the plan work for you Use it as a reference to understand

x Who is eligible for coverage under your plan x How to file a claim and get your benefits paid

x Your rights to appeal a claim payment or Medical Management decision

x What we mean by certain healthcare terms Knowing the details can make a difference in how satisfied you are with your plan and how easy it is for you to use If you have additional questions please visit wwwempirebluecom or call Member Services at 1-855-519-9537

Eligibility The eligibility rules and administrative procedures for adding and removing dependents for your coverage are sent out in an annually distributed official issuance of the United Nations Please do not contact Empire regarding enrollment or eligibility questions

52 wwwempirebluecom

Claims IF YOU NEED TO FILE A CLAIM

Empire makes healthcare easy by paying providers directly when you stay in-network Therefore when you receive care from providers or facilities in the Empire or BlueCard PPO networks you generally do not have to file a claim However you will have to file a claim for reimbursement for covered services received out-of-network from a non-participating provider or if you have a medical emergency out of the Empire service area To obtain a claim form call customer service

TYPE OF CLAIM IN-NETWORK OUT-OF-NETWORK

HOSPITAL Provider files claim directly with Empire or local Blue CrossBlue Shield plan

Provider files claim with Empire or local Blue CrossBlue Shield plan

MEDICAL Provider files claim directly with Empire or local Blue CrossBlue Shield plan You file claim with Empire

AMBULANCE CHARGES Provider files claim directly with Empire or local Blue CrossBlue Shield plan You file claim with Empire

At some out-of-area and non-participating hospitals you may have to pay the hospitalrsquos bill If this happens include an original itemized hospital bill with your claim

Send completed forms to

Hospital Claims

Empire BlueCross BlueShield PO Box 1407 Church Street Station New York NY 10008-1407 Attention Institutional Claims Department

Medical Claims

Empire BlueCross BlueShield PO Box 1407 Church Street Station New York NY 10008-1407 Attention Medical Claims Department

Want more claim information Now you can check the status of a claim view and print Explanation of Benefits (EOB) correct certain claim information and more at any time of day or night just by visiting wwwempirebluecom

Assignment

You authorize Empire on behalf of the Employer to make payments directly to participating In-Network Providers for Covered Services Empire also reserves the right to make payments directly to you Except where Empire expressly indicates otherwise in the case of services provided by an out of network provider payments will always be made directly to you for services provided by the out of network provider Payments may also be made to and notice regarding the receipt andor adjudication of claims an Alternate Recipient or that personrsquos custodial parent or designated representative Any payments made by Empire will discharge the Employerrsquos obligation to pay for Covered Services You cannot assign your right to receive payment to anyone else except as required by a ldquoQualified Medical Child Support orderrdquo as defined by ERISA or any applicable state or Federal law Once a Provider performs a Covered Service Empire will not honor a request to withhold payment of the claims submitted The coverage and any benefits under the Plan are not assignable by any Member without the written consent of the Plan except as provided above

wwwempirebluecom 53

Tips for Filing a Claim x File claims within 18 months of date of service x Visit wwwempirebluecom to print out a claim form immediately or contact Member Services at 1-855-519-9537

to have one mailed to you x Complete all information requested on the form x Submit all claims in English or with an English translation x Attach original bills or receipts Photocopies will not be accepted x If Empire is the secondary payer submit the original or a copy of the primary payerrsquos Explanation of Benefits (EOB)

with your itemized bill x Keep a copy of your claim form and all attachments for your records

REMEMBER File claims within 24 months of the date of service to receive benefits

IF YOU HAVE MEDICAL COVERAGE UNDER TWO PLANS (COORDINATION OF BENEFITS ndash COB) Empire has a coordination of benefits (COB) feature that applies when you and members of your family are covered under more than one health plan The benefits provided by Empire will be coordinated with any benefits you are eligible to receive under the other plan Together the plans will pay up to the amount of covered expenses but not more than the amount of actual expenses When you are covered under two plans one plan has primary responsibility to pay benefits and the other has secondary responsibility The plan with primary responsibility pays benefits first

FRAUD AND ABUSIVE BILLING We have processes to review claims before and after payment to detect fraud and abusive billing In addition We may identify certain Providers to review for potential fraud waste abuse or other inappropriate activity if the claims data suggests there may be inappropriate billing practices If a Provider is selected for review under this program then as part of the review process We may use one or more clinical utilization management guidelines in the review of claims submitted by this Provider even if those guidelines are not used for all Providers delivering services to the Planrsquos Members

Members seeking services from Non-Participating Providers could be balance billed by the Non-Participating Provider for those services that are determined to be not payable as a result of a reasonable belief of fraud or other intentional misconduct or abusive billing

Which Plan Pays Benefits First Here is how Empire determines which plan has primary responsibility for paying benefits

x If the other health plan does not have a coordination of benefits feature that plan is primary x If you are covered as an employee under the Empire plan and as a dependent under the other plan your Empire plan

is primary x For a dependent child covered under both parentsrsquo plans the primary plan is

The plan of the parent whose birthday comes earlier in the calendar year (month and day) The plan that has covered the parent for a longer period of time if the parents have the same birthday The fatherrsquos plan if the other plan does not follow the ldquobirthday rulerdquo and uses gender to determine primary

responsibility If the parents are divorced or separated (and there is no court decree establishing financial responsibility for the

childrsquos healthcare expenses) the plan covering the parent with custody is primary If the parent with custody is remarried his or her plan pays first the step-parentrsquos plan pays second and the non-

custodial parentrsquos plan pays third If the parents are divorced or separated and there is a court decree specifying which parent has financial

responsibility for the childrsquos healthcare expenses that parentrsquos plan is primary once the plan knows about the decree

x If you are actively employed your plan is primary in relation to a plan for laid-off or retired employees x If none of these rules apply the plan that has covered the patient longest is primary

If Empire Is the Secondary Plan If the Empire plan is secondary then benefits will be reduced so the total benefits paid by both plans will not be greater than the allowable expenses Also Empire will not pay more than the amount Empire would normally pay if Empire were primary

Tips for Coordinating Benefits x To receive all the benefits available to you file your claim under each plan x File claims first with the primary plan then with the secondary plan

54 wwwempirebluecom

x Include the original or a copy of the Explanation of Benefits (EOB) from the primary plan when you submit your bill to the secondary plan Remember to keep a copy for your records

If You Receive An Overpayment Of Benefits If you receive benefits that either should not have been paid or are more than should have been paid you must return any overpayment to Empire within 60 days of receiving it Overpayments include

x Payment for a service not covered by the plan x Payment for a person not covered by the plan x Payment that exceeds the amount due under your plan x Duplicate payments for the same services

Subrogation and Right of Reimbursement

These provisions apply when Plan benefits are paid as a result of injuries or illness you sustained and you have a right to a Recovery or have received a Recovery

Subrogation

The Administrator on behalf of the Employer has the right to recover Plan payments made on your behalf from any party responsible for compensating you for your injuries The following apply

x The Administrator on behalf of the Employer has the first priority for the full amount of benefits they have paid from any Recovery regardless of whether you are fully compensated and regardless of whether the payments you receive make you whole for your losses and injuries

x You and your legal representative must do whatever is necessary to enable the Administrator on behalf of the Employer to exercise their rights and do nothing to prejudice them

x The Administrator on behalf of the Employer has the right to take whatever legal action they see fit against any party or entity to recover the benefits paid under the Plan

x To the extent that the total assets from which a Recovery is available are insufficient to satisfy in full the Administrators subrogation claim and any claim still held by you The Administratorrsquos subrogation claim shall be first satisfied before any part of a Recovery is applied to your claim your attorney fees other expenses or costs

The Administrator on behalf of the Employer is not responsible for any attorney fees other expenses or costs without its prior written consent The Administrator on behalf of the Employer further agrees that the ldquocommon fundrdquo doctrine does not apply to any funds recovered by any attorney you hire regardless of whether funds recovered are used to repay benefits paid by the Administrator on behalf of the Employer

Reimbursement

If you obtain a Recovery and the Administrator on behalf of the Employer has not been repaid for the benefits the Administrator on behalf of the Employer paid on your behalf the Administrator on behalf of the Employer shall have a right to be repaid from the Recovery in the amount of the benefits paid on your behalf and the following apply

x You must reimburse the Administrator on behalf of the Employer to the extent of Plan benefits the Administrator on behalf of the Employer paid on your behalf from any Recovery

x Notwithstanding any allocation made in a settlement agreement or court order the Administrator on behalf of the Employer shall have a right of Recovery in first priority against any Recovery

x You and your legal representative must hold in trust for the Administrator on behalf of the Employer the proceeds of the gross Recovery (ie the total amount of your Recovery before attorney fees other expenses or costs) to be paid to the Administrator on behalf of the Employer immediately upon your receipt of the Recovery You must reimburse the Employer in first priority and without any set-off or reduction for attorney fees other expenses or costs The ldquocommon fundrdquo doctrine does not apply to any funds recovered by any attorney You hire regardless of whether funds recovered are used to repay benefits paid by the Administrator on behalf of the Employer

x If You fail to repay the Administrator on behalf of the Employer the Administrator on behalf of the Employer shall be entitled to deduct any of the unsatisfied portion of the amount of benefits the Administrator on behalf of the Employer has paid or the amount of your Recovery whichever is less from any future benefit under the Plan if The amount the Administrator on behalf of the Employer paid on your behalf is not repaid or otherwise

recovered by the Administrator on behalf of the Employer or You fail to cooperate

x In the event that You fail to disclose to the Administrator andor the Employer the amount of your settlement the Administrator on behalf of the Employer shall be entitled to deduct the amount of their lien from any future benefit under the Plan

wwwempirebluecom 55

x The Administrator on behalf of the Employer shall also be entitled to recover any of the unsatisfied portions of the amount they have paid or the amount of your settlement whichever is less directly from the Providers to whom the Administrator on behalf of the Employer has made payments In such a circumstance it may then be your obligation to pay the Provider the full billed amount and the Administrator on behalf of the Employer would not have any obligation to pay the Provider

The Administrator on behalf of the Employer is entitled to reimbursement from any Recovery in first priority even if the Recovery does not fully satisfy the judgment settlement or underlying claim for damages or fully compensate or make you whole

Your Duties

x You must notify the Administrator on behalf of the Employer promptly of how when and where an accident or incident resulting in personal injury or illness to you occurred and all information regarding the parties involved

x You must cooperate with the Administrator on behalf of the Employer in the investigation settlement and protection of the Employers rights of the Administrator on behalf of the Employer

x You must not do anything to prejudice the rights of the Administrator on behalf of the Employer x You must send the Administrator on behalf of the Employer copies of all police reports notices or other papers

received in connection with the accident or incident resulting in personal injury or illness to you x You must promptly notify the Administrator on behalf of the Employer if you retain an attorney or if a lawsuit is

filed on your behalf

Health Care Fraud Illegal activity adds to everyonersquos cost for healthcare Thatrsquos why Empire welcomes your help in fighting fraud If you know of any person receiving Empire benefits that they are not entitled to call us We will keep your identity confidential Want to see some recent examples of Empirersquos fraud prevention efforts Visit wwwempirebluecom

REMEMBER FRAUD HOTLINE 1-800-ICFRAUD (423-7283) During normal business hours

If You Have Questions About a Benefit Payment Empire reviews each claim for appropriate services and correct information before it is paid Once a claim is processed an Explanation of Benefits (EOB) will be sent directly to you if you have any responsibility on the claim other than your co-payment amount or if an adjustment is performed on your claim If Empire reduces or denies a claim payment you will receive a written notification or an Explanation of Benefits (EOB) citing the reasons your claim was reduced or denied The notification will give you

x The specific reason(s) for the denial x References to the pertinent plan provisions on which the denial is based x A description of any additional material or information necessary for you to establish the claim and an explanation of

why this material or information is necessary x An explanation of claims review procedures

If you have any questions about your claim your Benefits Administrator may be able to help you answer them You may also contact Empire Member Services at 1-855-519-9537 or in writing for more information When you call be sure to have your Empire ID card number handy along with any information about your claim Send written inquiries to

Empire BlueCross BlueShield PPO Member Services PO Box 1407 Church Street Station New York NY 10008-1407

56 wwwempirebluecom

Reimbursement For Covered Services Maximum Allowed Amount This section describes how We determine the amount of reimbursement for Covered Services Reimbursement for services rendered by In-Network and Out-of-Network Providers is based on the Maximum Allowed Amount for the Covered Service that you receive Please see the Blue Cross and Blue Shield Association BlueCard Program section for additional information regarding services received outside of Empirersquos service area

The Maximum Allowed Amount is the maximum amount of reimbursement Empire will pay for services and supplies

x that meet our definition of Covered Services to the extent such services and supplies are covered under Your

Plan and are not excluded x that are Medically Necessary and x that are provided in accordance with all applicable preauthorization Medical Management Programs or other

requirements set forth in Your Plan You will be required to pay a portion of the Maximum Allowed Amount to the extent you have not met your Deductible or have a Copayment or Coinsurance In addition when you receive Covered Services from an Out-of-Network Provider you may be responsible for paying any difference between the Maximum Allowed Amount and the Providerrsquos actual charges This amount can be significant

When you receive Covered Services from a Provider We will to the extent applicable apply claim processing rules to the claim submitted for those Covered Services These rules evaluate the claim information and determine among other things the appropriateness of the procedure and diagnosis codes included in the claim Applying these rules may affect our determination of the Maximum Allowed Amount Our application of these rules does not mean that the Covered Services you received were not Medically Necessary It means We have determined that the claim submitted was inconsistent with procedure coding rules andor our reimbursement policies For example your Provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed When this occurs the Maximum Allowed Amount will be based on the single procedure code rather than a separate Maximum Allowed Amount for each billed code Likewise when multiple procedures are performed on the same day by the same Provider or other healthcare professional We may reduce the Maximum Allowed Amounts for those secondary and subsequent procedures because reimbursement at 100 of the Maximum Allowed Amount for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive

PROVIDER NETWORK STATUS The Maximum Allowed Amount may vary depending upon whether the Provider is an In-Network Provider or an Out-of-Network Provider

For Covered Services performed by an In-Network Provider the Maximum Allowed Amount is the rate the Provider has agreed with Empire to accept as reimbursement for the Covered Services Because In-Network Providers have agreed to accept the Maximum Allowed Amount as payment in full for that service they should not send you a bill or collect for amounts above the Maximum Allowed Amount However you may receive a bill or be asked to pay all or a portion of the Maximum Allowed Amount to the extent that you have not met your Deductible or have a Copayment or Coinsurance Please call Customer Service for help in finding an In-Network Provider or visit wwwempirebluecom

Providers who have not signed any contract with Us and are not in any of our networks are Out-of-Network Providers subject to Blue Cross and Blue Shield Association rules governing claims filed by certain ancillary Providers

For Covered Services that you receive from an Out-of-Network Provider the Maximum Allowed Amount will be based on our Out-of-Network Provider fee schedulerate or the Out-of-Network Providerrsquos charge this amount is currently 275 of Medicarersquos Fee Schedule whichever is less (except Certified Social Worker 225 and Physical Therapy 200) Our Out-of-Network Provider fee schedulerate may be accessed by calling the Customer Service number on the back of your identification card The Maximum Allowed Amount on our Out-of-Network Provider fee schedulerate has been developed by reference to one or more of several sources including the following

wwwempirebluecom 57

1 Amounts based on our In-Network Provider fee schedulerate 2 Amounts based on the level andor method of reimbursement used by the Centers for Medicare and Medicaid

Services unadjusted for geographic locality for the same services or supplies Such reimbursement amounts will be updated no less than annually

3 Amounts based on charge cost reimbursement or utilization data 4 Amounts based on information provided by a third party vendor which may reflect one or more of the

following factors i) the complexity or severity of treatment ii) level of skill and experience required for the treatment or iii) comparable Providersrsquo fees and costs to deliver care or

5 An amount negotiated by the Claims Administrator or a third party vendor which has been agreed to by the Provider This may include rates for services coordinated through case management

The amount We pay a Non-Participating Provider for Emergency Services will be the greater of 1) the amount We have negotiated with Participating Providers for the Emergency Service (and if more than one amount is negotiated the median of the amounts) 2) 100 of the Allowed Amount for services provided by a Non-Participating Provider (ie the amount We would pay in the absence of any Cost-Sharing that would otherwise apply for services of Non-Participating Providers) or 3) the amount that would be paid under Medicare The amounts described above exclude any Copayment or Coinsurance that applies to Emergency Services provided by a Participating Provider For Covered Services rendered outside Empirersquos Service Area by Out-of-Network Providers claims may be priced using the local Blue Cross Blue Shield planrsquos non-participating provider fee schedule rate or the pricing arrangements required by applicable state or federal law In certain situations the Maximum Allowed Amount for out of area claims may be based on billed charges the pricing we would use if the healthcare services had been obtained within the Empire Service Area or a special negotiated price

Providers who are not contracted for this Plan but contracted for other Plans with Us are also considered Out-of-Network The Maximum Allowed Amount reimbursement for services from these Providers will be based on Our Out-of Network Provider fee schedulerate as described above unles